Healthcare Provider Details

I. General information

NPI: 1386896710
Provider Name (Legal Business Name): WILLIAM J BOOTH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2008
Last Update Date: 03/05/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 LINCOLN PARK BLVD. SUITE 390
KETTERING OH
45429
US

IV. Provider business mailing address

540 LINCOLN PARK BLVD. SUITE 390
KETTERING OH
45429
US

V. Phone/Fax

Practice location:
  • Phone: 937-296-1128
  • Fax: 937-296-1728
Mailing address:
  • Phone: 937-296-1128
  • Fax: 937-296-1728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.000525
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number50.000525RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: