Healthcare Provider Details

I. General information

NPI: 1548377518
Provider Name (Legal Business Name): ROBERT DOUGLAS BOOTH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 01/27/2025
Certification Date: 01/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1265 UNION AVE
MEMPHIS TN
38104-3415
US

IV. Provider business mailing address

1698 PEACH AVE
MEMPHIS TN
38112-5216
US

V. Phone/Fax

Practice location:
  • Phone: 901-516-7600
  • Fax:
Mailing address:
  • Phone: 901-830-8826
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number127045
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number6889
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1666
License Number StateME
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number399
License Number StateAR
# 5
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA04555
License Number StateTX
# 6
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA1459
License Number StateTN
# 7
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA04555
License Number StateTX
# 8
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA00081
License Number StateMS
# 9
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1459
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: