Provider Demographics
NPI:1316983448
Name:BOOS, KATHLEEN (MD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:BOOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 2493
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92659-1493
Mailing Address - Country:US
Mailing Address - Phone:657-241-3600
Mailing Address - Fax:657-241-7708
Practice Address - Street 1:520 SUPERIOR AVE STE 360
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3668
Practice Address - Country:US
Practice Address - Phone:949-644-1025
Practice Address - Fax:949-644-7852
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG81572207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG81572CMedicare PIN
CAWG81572BMedicare PIN