Healthcare Provider Details

I. General information

NPI: 1144406455
Provider Name (Legal Business Name): BOONYASAI & BOONYASAI, M.D.P. C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2008
Last Update Date: 01/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 ST . MARYS STREET LOWER LEVEL
PILOT KNOB MO
63663
US

IV. Provider business mailing address

200 ST. MARYS STREET PO BOX 527 LOWER LEVEL
PILOT KNOB MO
63663
US

V. Phone/Fax

Practice location:
  • Phone: 573-546-3929
  • Fax: 573-546-3962
Mailing address:
  • Phone: 573-546-3929
  • Fax: 573-546-3962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number33967
License Number StateMO

VIII. Authorized Official

Name: DR. BOONFU BOONYASAI
Title or Position: PRESIDENT
Credential: M.D.
Phone: 573-546-3929