Provider Demographics
NPI:1821309683
Name:BOONE, BRIAN (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:
Last Name:BOONE
Suffix:
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 1:15 EXCHANGE DR
Mailing Address - Street 2:
Mailing Address - City:LUGOFF
Mailing Address - State:SC
Mailing Address - Zip Code:29078-9198
Mailing Address - Country:US
Mailing Address - Phone:803-408-3277
Mailing Address - Fax:803-408-3299
Practice Address - Street 1:15 EXCHANGE DR
Practice Address - Street 2:
Practice Address - City:LUGOFF
Practice Address - State:SC
Practice Address - Zip Code:29078-9198
Practice Address - Country:US
Practice Address - Phone:803-408-3277
Practice Address - Fax:803-408-3299
Is Sole Proprietor?:No
Enumeration Date:2010-06-27
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN#14893207Y00000X
NC2014-02050207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC405458Medicaid