Provider Demographics
NPI:1700949286
Name:RATANAWONGSA, BOOSARA (MD)
Entity Type:Individual
Prefix:
First Name:BOOSARA
Middle Name:
Last Name:RATANAWONGSA
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 1:961 MARCON BLVD STE 452
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18109-9366
Mailing Address - Country:US
Mailing Address - Phone:610-398-9898
Mailing Address - Fax:610-398-9899
Practice Address - Street 1:961 MARCON BLVD STE 452
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18109-9366
Practice Address - Country:US
Practice Address - Phone:610-398-9898
Practice Address - Fax:610-398-9899
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4317692084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA47-1936111OtherEIN