Provider Demographics
NPI:1437188562
Name:BOONE, ERIC BRANDON (OD)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:BRANDON
Last Name:BOONE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 489
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32056-0489
Mailing Address - Country:US
Mailing Address - Phone:386-755-2785
Mailing Address - Fax:386-755-1128
Practice Address - Street 1:1615 SW MAIN BLVD
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-1108
Practice Address - Country:US
Practice Address - Phone:386-755-2785
Practice Address - Fax:386-755-1128
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3872152W00000X
FLOB3178152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00188323OtherRAILROAD MEDICARE
FL620976901Medicaid
FL620976900Medicaid
FL7952763OtherAETNA
1180560001OtherMEDICARE DMERC
FL001933700Medicaid
FL25001OtherBLUE CROSS BLUE SHIELD
FL298000OtherAVMED
FL001933700Medicaid
FL620976901Medicaid
FLU4163YMedicare PIN