Provider Demographics
NPI:1720600737
Name:BOODRAM, RACHEL TANYA (MD)
Entity Type:Individual
Prefix:MS
First Name:RACHEL
Middle Name:TANYA
Last Name:BOODRAM
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 803929
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-3929
Mailing Address - Country:US
Mailing Address - Phone:800-953-0104
Mailing Address - Fax:303-765-6670
Practice Address - Street 1:311 E SPRUCE ST
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:KS
Practice Address - Zip Code:67846-5614
Practice Address - Country:US
Practice Address - Phone:620-275-3730
Practice Address - Fax:620-275-3767
Is Sole Proprietor?:No
Enumeration Date:2020-05-13
Last Update Date:2023-09-21
Deactivation Date:2022-01-17
Deactivation Code:
Reactivation Date:2022-01-18
Provider Licenses
StateLicense IDTaxonomies
KS04-48165208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics