Provider Demographics
NPI:1265495139
Name:BOONE, KEITH B (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:B
Last Name:BOONE
Suffix:
Gender:M
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:PO BOX 28947
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93729-8947
Mailing Address - Country:US
Mailing Address - Phone:559-228-5448
Mailing Address - Fax:559-224-3920
Practice Address - Street 1:205 E RIVER PARK CIR
Practice Address - Street 2:SUITE 460
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-1571
Practice Address - Country:US
Practice Address - Phone:559-261-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG68568208600000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG15447Medicare UPIN