Provider Demographics
NPI:1861498909
Name:BOONE, KENDALL D (MD)
Entity Type:Individual
Prefix:DR
First Name:KENDALL
Middle Name:D
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 1:7974 UW HEALTH CT
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-5531
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1340 CHARLES ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104-2200
Practice Address - Country:US
Practice Address - Phone:779-696-8799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361011792086S0127X, 2086S0129X
WI668522086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2045754001OtherOWCP
IL194273OtherPERSONAL CARE
ILG53373Medicare UPIN
ILL89796Medicare PIN