Provider Demographics
NPI:1053511642
Name:BOONE, MIRA (MD)
Entity Type:Individual
Prefix:DR
First Name:MIRA
Middle Name:
Last Name:BOONE
Suffix:
Gender:F
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:MEDICAL CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27157-0001
Mailing Address - Country:US
Mailing Address - Phone:336-716-5599
Mailing Address - Fax:336-716-3202
Practice Address - Street 1:1534 W D ST
Practice Address - Street 2:
Practice Address - City:NORTH WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28659-3528
Practice Address - Country:US
Practice Address - Phone:336-667-4178
Practice Address - Fax:336-667-0938
Is Sole Proprietor?:No
Enumeration Date:2007-07-20
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2008-00571207Q00000X, 207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5909947Medicaid
NC2022742AMedicare PIN