Healthcare Provider Details

I. General information

NPI: 1073543781
Provider Name (Legal Business Name): GARY KENNETH BOONE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 11/19/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3737 MORAGA AVE STE B408
SAN DIEGO CA
92117-5364
US

IV. Provider business mailing address

3737 MORAGA AVE STE B408
SAN DIEGO CA
92117-5364
US

V. Phone/Fax

Practice location:
  • Phone: 858-292-8885
  • Fax: 858-292-0688
Mailing address:
  • Phone: 858-292-8885
  • Fax: 858-292-0688

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberG31968
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: