Healthcare Provider Details

I. General information

NPI: 1174552830
Provider Name (Legal Business Name): JEFFREY E BOOTH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 04/29/2022
Certification Date: 04/29/2022
Deactivation Date: 01/31/2022
Reactivation Date: 04/29/2022

III. Provider practice location address

4403 HARRISON BLVD STE 3650
OGDEN UT
84403-3271
US

IV. Provider business mailing address

PO BOX 27128
SALT LAKE CITY UT
84127-0128
US

V. Phone/Fax

Practice location:
  • Phone: 801-387-7125
  • Fax: 801-387-7130
Mailing address:
  • Phone: 801-387-7125
  • Fax: 801-387-7130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number771607311205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: