Provider Demographics
NPI:1194713602
Name:BOONE, CARROLL ROBERT (MD)
Entity type:Individual
Prefix:
First Name:CARROLL
Middle Name:ROBERT
Last Name:BOONE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7401 SOUTH MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-4509
Mailing Address - Country:US
Mailing Address - Phone:713-799-2300
Mailing Address - Fax:713-794-3380
Practice Address - Street 1:520 BLOSSOM ST
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598-4210
Practice Address - Country:US
Practice Address - Phone:281-332-9537
Practice Address - Fax:281-332-1560
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-10
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE3532207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX117064902Medicaid
TXC1306Medicare UPIN
TX117064902Medicaid