Provider Demographics
NPI:1033218060
Name:THADA, BOONYONG P (MD)
Entity Type:Individual
Prefix:DR
First Name:BOONYONG
Middle Name:P
Last Name:THADA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:BOONYONG
Other - Middle Name:
Other - Last Name:PHRUITHITHADA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5356 REISTERSTOWN ROAD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-4493
Mailing Address - Country:US
Mailing Address - Phone:410-358-5111
Mailing Address - Fax:410-358-9169
Practice Address - Street 1:5356 REISTERSTOWN ROAD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-4493
Practice Address - Country:US
Practice Address - Phone:410-358-5111
Practice Address - Fax:410-358-9169
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0019823207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
6729BMedicare ID - Type Unspecified
B69679Medicare UPIN