Provider Demographics
NPI:1730151457
Name:BOONE, BRADLEY A (MD)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:A
Last Name:BOONE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2111 14TH ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-4041
Mailing Address - Country:US
Mailing Address - Phone:601-693-3834
Mailing Address - Fax:601-484-3225
Practice Address - Street 1:3201 S AUSTIN AVE
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626-7545
Practice Address - Country:US
Practice Address - Phone:512-459-8753
Practice Address - Fax:512-483-6807
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK441172086S0129X
TXP83382086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK201292450AMedicaid
TX333764R401Medicaid