Provider Demographics
NPI:1295935716
Name:VAN DEN BOOM, ADAM MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:ADAM
Middle Name:MICHAEL
Last Name:VAN DEN BOOM
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 1:5430 FREDERICKSBURG RD STE 508
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3561
Mailing Address - Country:US
Mailing Address - Phone:210-541-8281
Mailing Address - Fax:210-541-9123
Practice Address - Street 1:5430 FREDERICKSBURG RD STE 508
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229
Practice Address - Country:US
Practice Address - Phone:210-541-8281
Practice Address - Fax:210-541-9123
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-23
Last Update Date:2018-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101243986208000000X, 208D00000X
TXR5670208000000X, 208M00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty