Provider Demographics
NPI:1164634655
Name:BOONSONG ANAN, M.D., INC
Entity Type:Organization
Organization Name:BOONSONG ANAN, M.D., INC
Other - Org Name:BOONSONG ANAN, M.D.,INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BOONSONG
Authorized Official - Middle Name:
Authorized Official - Last Name:ANAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-627-8522
Mailing Address - Street 1:5365 WALNUT AVE
Mailing Address - Street 2:SUITE P
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-2622
Mailing Address - Country:US
Mailing Address - Phone:909-627-8521
Mailing Address - Fax:909-563-8202
Practice Address - Street 1:5365 WALNUT AVE
Practice Address - Street 2:SUITE P
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-2622
Practice Address - Country:US
Practice Address - Phone:909-627-8521
Practice Address - Fax:909-563-8202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA316890208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA316890Medicaid
CA00A316890Medicare PIN
CAA26573Medicare UPIN