MEDICARE: BRADLEY A BOONE M.D.

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	2086S0129X	Vascular Surgery Physician	44117	OK
2	2086S0129X	Vascular Surgery Physician	P8338	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1730151457
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRADLEY A BOONE M.D.

Provider Business Mailing Address
First Line	:	2111 14TH ST
Second Line	:
City	:	MERIDIAN
State	:	MS
Zip	:	39301-4041
Country	:	US
Telephone Number	:	601-693-3834
Fax Number	:	601-484-3225

Provider Business Practice Location Address
First Line	:	3201 S AUSTIN AVE
Second Line	:
City	:	GEORGETOWN
State	:	TX
Zip	:	78626-7545
Country	:	US
Telephone Number	:	512-459-8753
Fax Number	:	512-483-6807

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

Provider Enumeration Date	:	02/06/2006
Last Update Date	:	10/29/2024

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Directions to “ BRADLEY A BOONE M.D.” Practice Location

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