Provider Demographics
NPI:1548155567
Name:CHAIWONGSA, AMPHA (OD)
Entity type:Individual
Prefix:
First Name:AMPHA
Middle Name:
Last Name:CHAIWONGSA
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 1:1310 WONDER WORLD DR STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:TX
Mailing Address - Zip Code:78666-8351
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1310 WONDER WORLD DR STE 100
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-8351
Practice Address - Country:US
Practice Address - Phone:737-200-8024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-10
Last Update Date:2025-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program