Provider Demographics
NPI:1417058959
Name:BOONKHAM, CHOTCHAI (MD)
Entity Type:Individual
Prefix:DR
First Name:CHOTCHAI
Middle Name:
Last Name:BOONKHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3478 BRIDGELAND DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-2619
Mailing Address - Country:US
Mailing Address - Phone:314-291-3717
Mailing Address - Fax:314-291-1671
Practice Address - Street 1:3478 BRIDGELAND DR
Practice Address - Street 2:SUITE 1
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2619
Practice Address - Country:US
Practice Address - Phone:314-291-3717
Practice Address - Fax:314-291-1671
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO34210207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO6900OtherBCBS PROVIDER ID
MO200701308Medicaid
MO000003793Medicare ID - Type UnspecifiedPROVIDER ID
MO200701308Medicaid