Provider Demographics
NPI:1326110354
Name:BOOMER, GREGORY A
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:A
Last Name:BOOMER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 A COTTAGE ST
Mailing Address - Street 2:
Mailing Address - City:SUSANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:96130-4303
Mailing Address - Country:US
Mailing Address - Phone:530-257-4424
Mailing Address - Fax:530-257-9626
Practice Address - Street 1:607 A COTTAGE ST
Practice Address - Street 2:
Practice Address - City:SUSANVILLE
Practice Address - State:CA
Practice Address - Zip Code:96130-4303
Practice Address - Country:US
Practice Address - Phone:530-257-4424
Practice Address - Fax:530-257-9626
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6622T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0782870001Medicare NSC