Basic Information
Provider Information | |||||||||
NPI: | 1730151457 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BOONE | ||||||||
FirstName: | BRADLEY | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2111 14TH ST | ||||||||
Address2: |   | ||||||||
City: | MERIDIAN | ||||||||
State: | MS | ||||||||
PostalCode: | 393014041 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6016933834 | ||||||||
FaxNumber: | 6014843225 | ||||||||
Practice Location | |||||||||
Address1: | 3201 S AUSTIN AVE | ||||||||
Address2: |   | ||||||||
City: | GEORGETOWN | ||||||||
State: | TX | ||||||||
PostalCode: | 786267545 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5124598753 | ||||||||
FaxNumber: | 5124836807 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/06/2006 | ||||||||
LastUpdateDate: | 01/25/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | P8338 | TX | Y |   | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
ID | Type | State | Issuer | Description | 333764R401 | 05 | TX |   | MEDICAID |