MEDICARE: DR. JEFFREY A BOOMER M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	04-31763	KS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396726964
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFREY A BOOMER M.D.

Provider Business Mailing Address
First Line	:	1100 N TOPEKA
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67214-2810
Country	:	US
Telephone Number	:	316-263-6273
Fax Number	:	316-263-5568

Provider Business Practice Location Address
First Line	:	1100 N TOPEKA
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67214-2810
Country	:	US
Telephone Number	:	316-263-6273
Fax Number	:	316-263-5568

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/09/2005
Last Update Date	:	12/23/2011

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