MEDICARE: DR. HAWKINS BOONE MECHAM D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	204C00000X	Sports Medicine (Neuromusculoskeletal Medicine) Physician	110996711204	UT
2	208D00000X	General Practice Physician	DO187716	OR
3	204D00000X	Neuromusculoskeletal Medicine & OMM Physician	11099671-1204	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	110996711204	OTHER	UT	STATE PROFESSIONAL LICENSE
2	110996718904	OTHER	UT	STATE CONTROLLED SUBSTANCE LICENSE

General Provider Information

NPI Number	:	1285080796
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HAWKINS BOONE MECHAM D.O.

Provider Business Mailing Address
First Line	:	2162 S 180 E STE 1000
Second Line	:
City	:	PROVO
State	:	UT
Zip	:	84606-7370
Country	:	US
Telephone Number	:	385-380-3425
Fax Number	:	855-873-2517

Provider Business Practice Location Address
First Line	:	2162 S 180 E # 1000
Second Line	:
City	:	PROVO
State	:	UT
Zip	:	84606-7370
Country	:	US
Telephone Number	:	385-380-3425
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/13/2016
Last Update Date	:	03/19/2025

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