Provider Demographics
NPI:1528204849
Name:BOOVER, ROBERT MARK (ABOC)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:MARK
Last Name:BOOVER
Suffix:
Gender:M
Credentials:ABOC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:369 W ESPLANADE AVE
Mailing Address - Street 2:
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70065-2541
Mailing Address - Country:US
Mailing Address - Phone:504-466-5400
Mailing Address - Fax:
Practice Address - Street 1:369 W ESPLANADE AVE
Practice Address - Street 2:
Practice Address - City:KENNER
Practice Address - State:LA
Practice Address - Zip Code:70065-2541
Practice Address - Country:US
Practice Address - Phone:504-466-5400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-17
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA30449156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician