Provider Demographics
NPI:1073543781
Name:BOONE, GARY KENNETH (MD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:KENNETH
Last Name:BOONE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3737 MORAGA AVE STE B408
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-5364
Mailing Address - Country:US
Mailing Address - Phone:858-292-8885
Mailing Address - Fax:858-292-0688
Practice Address - Street 1:3737 MORAGA AVE STE B408
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-5364
Practice Address - Country:US
Practice Address - Phone:858-292-8885
Practice Address - Fax:858-292-0688
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG31968207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G319680Medicaid
CA00G319680Medicaid
CAA44964Medicare UPIN
CA1073543781Medicare PIN
CAWG31968AMedicare ID - Type UnspecifiedNHIC SO CA MEDICARE