Provider Demographics
NPI:1194035097
Name:BOONYONG P THADA, M.D., P.A.
Entity Type:Organization
Organization Name:BOONYONG P THADA, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BOONYONG
Authorized Official - Middle Name:P
Authorized Official - Last Name:THADA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-358-5111
Mailing Address - Street 1:5356 REISTERSTOWN RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-4426
Mailing Address - Country:US
Mailing Address - Phone:410-358-5111
Mailing Address - Fax:410-358-9169
Practice Address - Street 1:5356 REISTERSTOWN RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-4426
Practice Address - Country:US
Practice Address - Phone:410-358-5111
Practice Address - Fax:410-358-9169
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BOONYONG P THADA, M.D., P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-10-14
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0019823207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD220561100Medicaid
MD220561100Medicaid