Provider Demographics
NPI:1336107796
Name:BOORMAN, ERIE V III (MD)
Entity Type:Individual
Prefix:
First Name:ERIE
Middle Name:V
Last Name:BOORMAN
Suffix:III
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 1:11645 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 901
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-6810
Mailing Address - Country:US
Mailing Address - Phone:310-481-0481
Mailing Address - Fax:310-481-0482
Practice Address - Street 1:11645 WILSHIRE BLVD
Practice Address - Street 2:SUITE 901
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-6810
Practice Address - Country:US
Practice Address - Phone:310-481-0481
Practice Address - Fax:310-481-0482
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG37331207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
W17914Medicare ID - Type Unspecified
B55944Medicare UPIN