Provider Demographics
NPI:1831586387
Name:POW-ANPONGKUL, PETE
Entity type:Individual
Prefix:
First Name:PETE
Middle Name:
Last Name:POW-ANPONGKUL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11180 WARNER AVE STE 351
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-7516
Mailing Address - Country:US
Mailing Address - Phone:714-698-0300
Mailing Address - Fax:714-698-0313
Practice Address - Street 1:11180 WARNER AVE STE 351
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-7516
Practice Address - Country:US
Practice Address - Phone:714-698-0300
Practice Address - Fax:714-698-0313
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-22
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA144575207R00000X, 207RH0000X, 207RX0202X, 207RH0003X
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematologyGroup - Multi-Specialty
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical OncologyGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA477476OtherMEDICARE
CACA477475OtherMEDICARE
CACB375979OtherMEDICARE