Healthcare Provider Details

I. General information

NPI: 1851567739
Provider Name (Legal Business Name): STEPHANIE RENEE BOOTH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: STEPHANIE RENEE BOOTH-MILLEN

II. Dates (important events)

Enumeration Date: 05/01/2008
Last Update Date: 05/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4580 ATLANTIC AVENUE
LONG BEACH CA
90807-0503
US

IV. Provider business mailing address

PO BOX 7503
LONG BEACH CA
90807-0503
US

V. Phone/Fax

Practice location:
  • Phone: 562-335-0551
  • Fax:
Mailing address:
  • Phone: 562-335-0551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG062886
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: