Provider Demographics
NPI:1629084082
Name:BOONE, MELCHOR MENCHACA JR (MD)
Entity Type:Individual
Prefix:
First Name:MELCHOR
Middle Name:MENCHACA
Last Name:BOONE
Suffix:JR
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 99335
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76199-0335
Mailing Address - Country:US
Mailing Address - Phone:817-927-1065
Mailing Address - Fax:817-927-1162
Practice Address - Street 1:855 MONTGOMERY ST
Practice Address - Street 2:DEPT OF OB/GYN
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-2553
Practice Address - Country:US
Practice Address - Phone:817-920-6401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH7914207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX129209607Medicaid
TXP00612405OtherRAILROAD MEDICARE
TX8B5597OtherBCBS
TXP00612405OtherRAILROAD MEDICARE
TX129209607Medicaid