Provider Demographics
NPI:1134198005
Name:BOONVISUDHI, KITIMA
Entity type:Individual
Prefix:DR
First Name:KITIMA
Middle Name:
Last Name:BOONVISUDHI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1189
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1189
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 HICKORY ST NW STE 101
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321-1700
Practice Address - Country:US
Practice Address - Phone:541-812-3360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY204411208600000X
WI59966208600000X
ORMD167013208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02440095Medicaid
NYH29174Medicare UPIN
NY02440095Medicaid