Provider Demographics
NPI:1295738516
Name:WATTANAMANO, PORNTHEP (MD)
Entity type:Individual
Prefix:DR
First Name:PORNTHEP
Middle Name:
Last Name:WATTANAMANO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3335 RIVIERA DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-6614
Mailing Address - Country:US
Mailing Address - Phone:713-384-3229
Mailing Address - Fax:
Practice Address - Street 1:3335 RIVIERA DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-6614
Practice Address - Country:US
Practice Address - Phone:713-384-3229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC186338207R00000X, 207RI0200X
TXL5950207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX157125902Medicaid
TXP00193508OtherRAILROAD MEDICARE
TX8R0570OtherBLUE CROSS BLUE SHIELD
TXP00193508OtherRAILROAD MEDICARE
743125941OtherEIN
TXG64924Medicare UPIN