Provider Demographics
NPI:1528139359
Name:BOONPONGMANEE, SOMPRAK (MD)
Entity type:Individual
Prefix:DR
First Name:SOMPRAK
Middle Name:
Last Name:BOONPONGMANEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8819 W. VICTORIA AVE
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336
Mailing Address - Country:US
Mailing Address - Phone:509-460-5500
Mailing Address - Fax:509-460-5111
Practice Address - Street 1:8819 W. VICTORIA AVE
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336
Practice Address - Country:US
Practice Address - Phone:509-460-5500
Practice Address - Fax:509-460-5111
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00042206207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8354037Medicaid
WA0207386OtherLABOR AND INDUSTRIES
P00289575OtherRR MEDICARE
H75710Medicare UPIN
WA0207386OtherLABOR AND INDUSTRIES