Provider Demographics
NPI:1619248853
Name:CHOTCHAI BOONKHAM MD PC
Entity Type:Organization
Organization Name:CHOTCHAI BOONKHAM MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHOTCHAI
Authorized Official - Middle Name:
Authorized Official - Last Name:BOONKHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:314-291-3717
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-19
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO34210261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care