Provider Demographics
NPI:1023103025
Name:BORIBOON, KINGKHAN (MD)
Entity type:Individual
Prefix:MRS
First Name:KINGKHAN
Middle Name:
Last Name:BORIBOON
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 1:3850 PELHAM ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-3832
Mailing Address - Country:US
Mailing Address - Phone:313-562-9500
Mailing Address - Fax:313-562-7567
Practice Address - Street 1:3850 PELHAM ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-3832
Practice Address - Country:US
Practice Address - Phone:313-562-9500
Practice Address - Fax:313-562-7567
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010315432080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIE37969Medicare UPIN