Provider Demographics
NPI:1942422274
Name:BOONE, SHELLEY K (MD)
Entity Type:Individual
Prefix:DR
First Name:SHELLEY
Middle Name:K
Last Name:BOONE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1643 W LANE AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43221-3339
Mailing Address - Country:US
Mailing Address - Phone:614-775-1503
Mailing Address - Fax:
Practice Address - Street 1:1643 W LANE AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43221-3339
Practice Address - Country:US
Practice Address - Phone:614-775-1503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.088642208100000X, 2081S0010X
MDD71035208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD540041400Medicaid
OH2763531Medicaid
MD540041400Medicaid