Healthcare Provider Details

I. General information

NPI: 1215023023
Provider Name (Legal Business Name): RENE A BOOTHBY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 05/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

FLORIDA ENT & ALLERGY 5105 N ARMENIA AVE
TAMPA FL
33603-1405
US

IV. Provider business mailing address

SELECT PHYSICIANS ALLIANCE 10002 PRINCESS PALM AVE. STE 332
TAMPA FL
33619-8327
US

V. Phone/Fax

Practice location:
  • Phone: 813-879-8045
  • Fax: 813-876-6504
Mailing address:
  • Phone: 813-571-7184
  • Fax: 813-654-4695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License NumberME44406
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberME0044406
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: