Provider Demographics
NPI:1639151384
Name:KOSARUSSAVADI, BOONSRI (MD)
Entity type:Individual
Prefix:
First Name:BOONSRI
Middle Name:
Last Name:KOSARUSSAVADI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 GEORGE ST
Mailing Address - Street 2:6TH FLOOR PO BOX 9805
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-6624
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 YORK ST
Practice Address - Street 2:YALE NEW HAVEN HOSPITAL
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3220
Practice Address - Country:US
Practice Address - Phone:203-785-2802
Practice Address - Fax:203-785-6664
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT016869207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001168699Medicaid
D02436Medicare UPIN
CT050000062Medicare ID - Type Unspecified