1285769000 NPI number — B. RATANAWONGSA, MD, PC

Table of content: (NPI 1285769000)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285769000 NPI number — B. RATANAWONGSA, MD, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
B. RATANAWONGSA, MD, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285769000
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5 CIRCLE OAK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALLEGANY
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14706-1101
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-373-0444
Provider Business Mailing Address Fax Number:
716-373-5031

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2223 W STATE ST
Provider Second Line Business Practice Location Address:
SUITE 107
Provider Business Practice Location Address City Name:
OLEAN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14760-1938
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-373-0444
Provider Business Practice Location Address Fax Number:
716-373-5031
Provider Enumeration Date:
02/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RATANAWONGSA
Authorized Official First Name:
BOONLUA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
716-373-0444

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  118639-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00590010 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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