Provider Demographics
NPI:1386709202
Name:VISALIA WOMEN'S SPECIALTY MEDICAL GROUP, INC
Entity type:Organization
Organization Name:VISALIA WOMEN'S SPECIALTY MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:B
Authorized Official - Last Name:BOONE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:559-741-1202
Mailing Address - Street 1:1700 S COURT ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93277-4929
Mailing Address - Country:US
Mailing Address - Phone:559-741-1202
Mailing Address - Fax:559-741-0123
Practice Address - Street 1:1700 S COURT ST
Practice Address - Street 2:SUITE B
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93277-4929
Practice Address - Country:US
Practice Address - Phone:559-741-1202
Practice Address - Fax:559-741-0123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-22
Last Update Date:2017-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0080010Medicaid
CAZZZ13871ZMedicare ID - Type Unspecified