Provider Demographics
NPI:1013154384
Name:BOON, JOHN REYNOLDS (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:REYNOLDS
Last Name:BOON
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 1:16651 SOUTHWEST FWY
Mailing Address - Street 2:MOB 1 SUITE 310
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479-2345
Mailing Address - Country:US
Mailing Address - Phone:281-565-1250
Mailing Address - Fax:
Practice Address - Street 1:16651 SOUTHWEST FWY
Practice Address - Street 2:MOB 1 SUITE 310
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77479-2345
Practice Address - Country:US
Practice Address - Phone:281-565-1250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-08
Last Update Date:2014-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN2957208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1813154384OtherBLUE CROSS BLUE SHIELD
TX280592101Medicaid
TX280592102Medicaid
TXP01062995OtherRAILROAD MEDICARE
TXP00748658OtherRAILROAD MEDICARE
TXP00748658OtherRAILROAD MEDICARE
TXTXB151708Medicare PIN
TX280592102Medicaid
TXTXB151707Medicare PIN