Provider Demographics
NPI:1336272392
Name:BOOMAN, JOHN DAVID (DO)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:DAVID
Last Name:BOOMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13006 W BEAVER RD
Mailing Address - Street 2:
Mailing Address - City:SPRING GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55974-2463
Mailing Address - Country:US
Mailing Address - Phone:507-498-5445
Mailing Address - Fax:507-498-3577
Practice Address - Street 1:102 1ST ST SE
Practice Address - Street 2:
Practice Address - City:SPRING GROVE
Practice Address - State:MN
Practice Address - Zip Code:55974
Practice Address - Country:US
Practice Address - Phone:507-498-5445
Practice Address - Fax:507-498-3577
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2367111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN231665OtherCHIRO CARE OF MN PROV NO.
MN06952BOOtherBCBS PROVIDER NUMBER
MNT39479Medicare UPIN