Healthcare Provider Details

I. General information

NPI: 1376238444
Provider Name (Legal Business Name): KAILIP BOONRAI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2023
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 SENECA AVE
RIDGEWOOD NY
11385-6067
US

IV. Provider business mailing address

629 PARK PL
BROOKLYN NY
11238
US

V. Phone/Fax

Practice location:
  • Phone: 718-571-6300
  • Fax:
Mailing address:
  • Phone: 914-798-8971
  • Fax: 854-300-4928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number341301
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: