Provider Demographics
NPI:1649481730
Name:BOONE, JOHN A (DO)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:BOONE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 S JEFFERSON ST
Mailing Address - Street 2:SUITE 416
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1705
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1314 PETERS CREEK RD NW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24017-2500
Practice Address - Country:US
Practice Address - Phone:540-562-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116016566207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA017972C18Medicare PIN
VA015752C23Medicare PIN