Basic Information
| Provider Information | |||||||||
| NPI: | 1720083447 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOORMAN | ||||||||
| FirstName: | ANITA | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9930 TALBERT AVE. | ||||||||
| Address2: | |||||||||
| City: | FOUNTAIN VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92708 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 9930 TALBERT AVE. | ||||||||
| Address2: | |||||||||
| City: | FOUNTAIN VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149646229 | ||||||||
| FaxNumber: | 7143786233 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2005 | ||||||||
| LastUpdateDate: | 09/22/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 20A7268 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0020A72680 | 01 | CA | MEDI CAL # | OTHER |