MEDICARE: DR. SALLY A BOOTH MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	ME142799	FL
2	207ND0101X	MOHS-Micrographic Surgery Physician	01042816A	IN
3	207NS0135X	Procedural Dermatology Physician	01042816A	IN
4	207N00000X	Dermatology Physician	01042816A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000375169	OTHER	IN	ANTHEM PIN

General Provider Information

NPI Number	:	1669452884
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SALLY A BOOTH MD

Provider Business Mailing Address
First Line	:	12050 N MICHIGAN RD
Second Line	:
City	:	ZIONSVILLE
State	:	IN
Zip	:	46077-8782
Country	:	US
Telephone Number	:	317-848-2427
Fax Number	:	317-848-2434

Provider Business Practice Location Address
First Line	:	12050 N MICHIGAN RD
Second Line	:
City	:	ZIONSVILLE
State	:	IN
Zip	:	46077-8782
Country	:	US
Telephone Number	:	317-848-2427
Fax Number	:	317-848-2434

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/23/2006
Last Update Date	:	01/26/2021

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Directions to “ DR. SALLY A BOOTH MD” Practice Location

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