Provider Demographics
NPI:1093798753
Name:BOONE, DAVID WESLEY (DO)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:WESLEY
Last Name:BOONE
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 1:8043 RIVOLI RD UNIT 428
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROKE
Mailing Address - State:GA
Mailing Address - Zip Code:31004-3019
Mailing Address - Country:US
Mailing Address - Phone:478-744-1710
Mailing Address - Fax:
Practice Address - Street 1:856 1ST ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-6875
Practice Address - Country:US
Practice Address - Phone:478-741-1740
Practice Address - Fax:478-745-2887
Is Sole Proprietor?:No
Enumeration Date:2005-11-26
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3936207W00000X
CT043122207W00000X
IN02003130A207W00000X
GA73540207WX0009X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0009XAllopathic & Osteopathic PhysiciansOphthalmologyGlaucoma Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000495130OtherANTHEM
IN200838980Medicaid
000000495130OtherANTHEM
IN859910RRRRMedicare PIN
I36347Medicare UPIN
IN200838980Medicaid
GAGRP7960Medicare PIN
IN859940DMedicare PIN
IN192770KKKKMedicare PIN
IN265130WWMedicare PIN