Provider Demographics
NPI:1699872358
Name:KEOMUAN, POONSRI (MD)
Entity type:Individual
Prefix:
First Name:POONSRI
Middle Name:
Last Name:KEOMUAN
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 1:1700 LANDMARK RD
Mailing Address - Street 2:AURORA VA CLINIC
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506-1167
Mailing Address - Country:US
Mailing Address - Phone:630-859-2504
Mailing Address - Fax:630-859-2508
Practice Address - Street 1:1700 LANDMARK RD
Practice Address - Street 2:AURORA VA CLINIC
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-1167
Practice Address - Country:US
Practice Address - Phone:630-859-2504
Practice Address - Fax:630-859-2508
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILVAD0000Medicare UPIN