Healthcare Provider Details

I. General information

NPI: 1104822832
Provider Name (Legal Business Name): KEVIN CHARLES BOOTH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 GREENLEY RD STE 914
SONORA CA
95370-5287
US

IV. Provider business mailing address

900 GREENLEY RD STE 914
SONORA CA
95370-5287
US

V. Phone/Fax

Practice location:
  • Phone: 95-365-7782
  • Fax: 209-536-5779
Mailing address:
  • Phone: 209-536-5778
  • Fax: 925-924-1769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberG77956
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: