Provider Demographics
NPI:1326008533
Name:BOONYASAI, VATANA C (MD/)
Entity Type:Individual
Prefix:
First Name:VATANA
Middle Name:C
Last Name:BOONYASAI
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:PO BOX 527
Mailing Address - Street 2:
Mailing Address - City:PILOT KNOB
Mailing Address - State:MO
Mailing Address - Zip Code:63663-0527
Mailing Address - Country:US
Mailing Address - Phone:573-546-3929
Mailing Address - Fax:573-546-3962
Practice Address - Street 1:200 ST.MARY'S STREET
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:PILOT KNOB
Practice Address - State:MO
Practice Address - Zip Code:63650
Practice Address - Country:US
Practice Address - Phone:573-546-3929
Practice Address - Fax:573-546-3962
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO33968207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO00009671Medicare ID - Type Unspecified
MOA27207Medicare UPIN