Provider Demographics
NPI:1255523569
Name:BOONE, SUSAN L (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:BOONE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9201 BIG HORN BLVD
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-1240
Mailing Address - Country:US
Mailing Address - Phone:916-478-5660
Mailing Address - Fax:916-478-5665
Practice Address - Street 1:9201 BIG HORN BLVD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95864
Practice Address - Country:US
Practice Address - Phone:916-478-5660
Practice Address - Fax:916-478-5665
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL125052276207N00000X
CAA118004207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology