MEDICARE: DR. KITIMA BOONVISUDHI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician	204411	NY
2	208600000X	Surgery Physician	59966	WI
3	208600000X	Surgery Physician	MD167013	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1134198005
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KITIMA BOONVISUDHI

Provider Business Mailing Address
First Line	:	PO BOX 1189
Second Line	:
City	:	CORVALLIS
State	:	OR
Zip	:	97339-1189
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	400 HICKORY ST NW STE 101
Second Line	:
City	:	ALBANY
State	:	OR
Zip	:	97321-1700
Country	:	US
Telephone Number	:	541-812-3360
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/14/2006
Last Update Date	:	01/27/2025

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