Provider Demographics
NPI:1073794764
Name:BOINEPALLI, PRATIMA (MD)
Entity Type:Individual
Prefix:
First Name:PRATIMA
Middle Name:
Last Name:BOINEPALLI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 SOUTH US. 27
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:MI
Mailing Address - Zip Code:48879-2437
Mailing Address - Country:US
Mailing Address - Phone:989-224-3000
Mailing Address - Fax:989-224-1424
Practice Address - Street 1:1055 SOUTH US. 27
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:MI
Practice Address - Zip Code:48879-2437
Practice Address - Country:US
Practice Address - Phone:989-224-3000
Practice Address - Fax:989-224-1424
Is Sole Proprietor?:No
Enumeration Date:2007-11-21
Last Update Date:2009-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301085879208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics