Healthcare Provider Details

I. General information

NPI: 1568461002
Provider Name (Legal Business Name): EDGAR ALAN BOONE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 04/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 WEST HOSPITAL DRIVE
WHITERIVER AZ
85941-0860
US

IV. Provider business mailing address

P.O.BOX 860
WHITERIVER AZ
85941-0860
US

V. Phone/Fax

Practice location:
  • Phone: 928-338-4911
  • Fax: 928-338-5508
Mailing address:
  • Phone: 928-338-4911
  • Fax: 928-338-5508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD027914E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: