Healthcare Provider Details

I. General information

NPI: 1023103025
Provider Name (Legal Business Name): KINGKHAN BORIBOON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3850 PELHAM ST
DEARBORN MI
48124-3832
US

IV. Provider business mailing address

3850 PELHAM ST
DEARBORN MI
48124-3832
US

V. Phone/Fax

Practice location:
  • Phone: 313-562-9500
  • Fax: 313-562-7567
Mailing address:
  • Phone: 313-562-9500
  • Fax: 313-562-7567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number4301031543
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: