Provider Demographics
NPI:1619047917
Name:RATANAWONGSA, BOONLUA (MD)
Entity Type:Individual
Prefix:DR
First Name:BOONLUA
Middle Name:
Last Name:RATANAWONGSA
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 1:2223 W STATE ST
Mailing Address - Street 2:SUITE 107
Mailing Address - City:OLEAN
Mailing Address - State:NY
Mailing Address - Zip Code:14760-1938
Mailing Address - Country:US
Mailing Address - Phone:716-373-0444
Mailing Address - Fax:716-373-5031
Practice Address - Street 1:2223 W STATE ST
Practice Address - Street 2:SUITE 107
Practice Address - City:OLEAN
Practice Address - State:NY
Practice Address - Zip Code:14760-1938
Practice Address - Country:US
Practice Address - Phone:716-373-0444
Practice Address - Fax:716-373-5031
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY118639-1207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00590010Medicaid
NY00590010Medicaid
NYB71589Medicare UPIN
PA063743Medicare PIN