Provider Demographics
NPI:1639189020
Name:ANAN, BOONSONG (MD)
Entity Type:Individual
Prefix:
First Name:BOONSONG
Middle Name:
Last Name:ANAN
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 1:5365 WALNUT AVE
Mailing Address - Street 2:SUITE P
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-2622
Mailing Address - Country:US
Mailing Address - Phone:909-627-8521
Mailing Address - Fax:909-563-8202
Practice Address - Street 1:5365 WALNUT AVE
Practice Address - Street 2:SUITE P
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-2622
Practice Address - Country:US
Practice Address - Phone:909-627-8521
Practice Address - Fax:909-563-8202
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA316890208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA316890Medicaid
CAA316890Medicaid
CAA26573Medicare UPIN