Provider Demographics
NPI:1942236542
Name:BOONE, WILLIE BENTON (MD)
Entity Type:Individual
Prefix:
First Name:WILLIE
Middle Name:BENTON
Last Name:BOONE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:W.
Other - Middle Name:BENTON
Other - Last Name:BOONE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:25 TRAMONTO DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-5387
Mailing Address - Country:US
Mailing Address - Phone:310-265-9313
Mailing Address - Fax:310-265-8434
Practice Address - Street 1:25 TRAMONTO DR
Practice Address - Street 2:
Practice Address - City:RANCHO PALOS VERDES
Practice Address - State:CA
Practice Address - Zip Code:90275-5387
Practice Address - Country:US
Practice Address - Phone:310-265-9313
Practice Address - Fax:310-265-8434
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-24
Last Update Date:2013-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG13745207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG13745COtherINDIVIDUAL PROVIDER TRANSACTION ACCESS NUMBER (PTAN)
CA00G137450Medicaid
CAG13745OtherCA LICENSE
CAA39077Medicare UPIN