Healthcare Provider Details

I. General information

NPI: 1609035781
Provider Name (Legal Business Name): JOHN LUTHER BOONE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2008
Last Update Date: 11/17/2022
Certification Date: 11/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14020 HWY 13 S STE 350
SAVAGE MN
55378-7103
US

IV. Provider business mailing address

14020 HWY 13 S STE 350
SAVAGE MN
55378-7103
US

V. Phone/Fax

Practice location:
  • Phone: 952-395-2500
  • Fax:
Mailing address:
  • Phone: 952-395-2500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number56270
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: