Healthcare Provider Details

I. General information

NPI: 1669419743
Provider Name (Legal Business Name): MICHAEL H BOOTHBY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 10/08/2020
Certification Date: 10/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 ACME BRICK PLZ
FORT WORTH TX
76109-4124
US

IV. Provider business mailing address

2901 ACME BRICK PLZ
FORT WORTH TX
76109-4124
US

V. Phone/Fax

Practice location:
  • Phone: 817-529-1900
  • Fax: 817-529-1910
Mailing address:
  • Phone: 817-529-1900
  • Fax: 817-529-1910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberM1030
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: