Provider Demographics
NPI:1417928870
Name:BOONE, CAROLYN JEAN (MD)
Entity Type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:JEAN
Last Name:BOONE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:505 W LEIGH ST
Mailing Address - Street 2:102
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23220-3200
Mailing Address - Country:US
Mailing Address - Phone:804-783-8788
Mailing Address - Fax:804-253-0204
Practice Address - Street 1:505 W LEIGH ST
Practice Address - Street 2:102
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23220-3200
Practice Address - Country:US
Practice Address - Phone:804-783-8788
Practice Address - Fax:804-253-0204
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-01
Last Update Date:2012-11-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101038253208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006799329Medicaid
VAD780267Medicare UPIN