Provider Demographics
NPI:1740665553
Name:CHARIYAWONG, PHUMPATTRA (MD)
Entity type:Individual
Prefix:
First Name:PHUMPATTRA
Middle Name:
Last Name:CHARIYAWONG
Suffix:
Gender:F
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:PO BOX 61160
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78466-1160
Mailing Address - Country:US
Mailing Address - Phone:361-884-2904
Mailing Address - Fax:361-857-0572
Practice Address - Street 1:3315 S ALAMEDA ST
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-1820
Practice Address - Country:US
Practice Address - Phone:877-332-4602
Practice Address - Fax:361-857-0572
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-22
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXT3600207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXT3600OtherTEXAS MEDICAL BOARD