Healthcare Provider Details

I. General information

NPI: 1720600737
Provider Name (Legal Business Name): RACHEL TANYA BOODRAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2020
Last Update Date: 09/21/2023
Certification Date: 09/21/2023
Deactivation Date: 01/17/2022
Reactivation Date: 01/18/2022

III. Provider practice location address

311 E SPRUCE ST
GARDEN CITY KS
67846-5614
US

IV. Provider business mailing address

PO BOX 803929
KANSAS CITY MO
64180-3929
US

V. Phone/Fax

Practice location:
  • Phone: 620-275-3730
  • Fax: 620-275-3767
Mailing address:
  • Phone: 800-953-0104
  • Fax: 303-765-6670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number04-48165
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: