Healthcare Provider Details

I. General information

NPI: 1255523569
Provider Name (Legal Business Name): SUSAN L BOONE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9201 BIG HORN BLVD 2ND FLOOR
SACRAMENTO CA
95864
US

IV. Provider business mailing address

9201 BIG HORN BLVD
ELK GROVE CA
95758-1240
US

V. Phone/Fax

Practice location:
  • Phone: 916-478-5660
  • Fax: 916-478-5665
Mailing address:
  • Phone: 916-478-5660
  • Fax: 916-478-5665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number125052276
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberA118004
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: