Provider Demographics
NPI:1124014030
Name:RATANA, KENNY (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNY
Middle Name:
Last Name:RATANA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:KAMCHAI
Other - Middle Name:
Other - Last Name:RATANACHINAKORN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:121 WESTMOUNT DR APT 84
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-3502
Mailing Address - Country:US
Mailing Address - Phone:573-358-3833
Mailing Address - Fax:
Practice Address - Street 1:527 BENHAM ST # B
Practice Address - Street 2:
Practice Address - City:BONNE TERRE
Practice Address - State:MO
Practice Address - Zip Code:63628-1205
Practice Address - Country:US
Practice Address - Phone:573-358-3833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR2H162085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOA12630Medicare UPIN