1154301117 NPI number — MICHAEL K BOONE MD

Table of content: MICHAEL K BOONE MD (NPI 1154301117)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154301117 NPI number — MICHAEL K BOONE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOONE
Provider First Name:
MICHAEL
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154301117
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/28/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3100 N LEE TREVINO DR STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EL PASO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79936-2116
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
915-533-7465
Provider Business Mailing Address Fax Number:
915-534-1185

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3100 N LEE TREVINO DR STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EL PASO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79936-2116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
915-533-7465
Provider Business Practice Location Address Fax Number:
915-534-1185
Provider Enumeration Date:
01/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , with the licence number:  H4177 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 114946002 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com