Provider Demographics
NPI:1073514642
Name:BOONJARERN, SAMPANTA (MD)
Entity Type:Individual
Prefix:
First Name:SAMPANTA
Middle Name:
Last Name:BOONJARERN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:855 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-4420
Mailing Address - Country:US
Mailing Address - Phone:708-492-4531
Mailing Address - Fax:708-763-0970
Practice Address - Street 1:297 FRANCISCAN DR
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-4858
Practice Address - Country:US
Practice Address - Phone:219-622-1718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01027321A207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000095595OtherANTHEM BCBS NUMBER
IN100168430AMedicaid
IN100082060Medicaid
IL090001077OtherIL BCBS NUMBER
IN628850Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER
IL090001077OtherIL BCBS NUMBER
INE05578Medicare UPIN
IN100168430AMedicaid
IN622850BMedicare PIN