Healthcare Provider Details

I. General information

NPI: 1205832425
Provider Name (Legal Business Name): WILLIAM DAVID BOOTHE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 01/22/2020
Certification Date: 01/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12210 QUAKER AVE STE 3
LUBBOCK TX
79424-7942
US

IV. Provider business mailing address

12210 QUAKER AVE
LUBBOCK TX
79424-1197
US

V. Phone/Fax

Practice location:
  • Phone: 806-792-5900
  • Fax: 806-792-6092
Mailing address:
  • Phone: 806-792-5900
  • Fax: 806-792-6092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberF3769
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: