Provider Demographics
NPI:1104072206
Name:CHAROENCHOTE, WANWALEE (OD)
Entity type:Individual
Prefix:
First Name:WANWALEE
Middle Name:
Last Name:CHAROENCHOTE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5820 PROSPECTOR TRL
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89118-2052
Mailing Address - Country:US
Mailing Address - Phone:702-501-7613
Mailing Address - Fax:
Practice Address - Street 1:4000 MEADOWS LN
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89107-3108
Practice Address - Country:US
Practice Address - Phone:702-259-4287
Practice Address - Fax:702-878-8445
Is Sole Proprietor?:No
Enumeration Date:2008-08-08
Last Update Date:2016-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV593152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist