Basic Information
| Provider Information | |||||||||
| NPI: | 1649487570 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOODGAME | ||||||||
| FirstName: | BOONE | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 RIO GRANDE ST | ||||||||
| Address2: | SUITE 340 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787011137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123248960 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1180 SETON PKWY | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | KYLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786406178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5125040865 | ||||||||
| FaxNumber: | 5125040863 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2007 | ||||||||
| LastUpdateDate: | 10/09/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RX0202X | 2004016554 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 215859403 | 05 | TX | MEDICAID | 215859404 | 05 | TX | MEDICAID |