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General NPI Number Information
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NPI Number | 1578598074
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Entity Type | Individual
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Provider Name | WALTER MARK BOOMER MD
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Gender | Male
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Dates
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Enumeration Date | 07/12/2006
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Last Update Date | 10/28/2021
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Provider Practice Location Address
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Address Line | 2832 E 101ST ST
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City | TULSA
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State | OK
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Zip | 74137-5601
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Country | US
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Telephone | 918-771-4455
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Fax | 918-771-4447
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Provider Business Mailing Address
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Address Line | PO BOX 3478 DEPT A
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City | TULSA
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State | OK
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Zip | 74101-3478
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Country | US
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Telephone | 918-494-9288
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Fax | 918-494-9289
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RP1001X
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Taxonomy Name | Pulmonary Disease Physician
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License Number | 17300
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License Number State | OK
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