=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083694970
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RICHARD BOOTH JR. M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2006
-----------------------------------------------------
Last Update Date | 11/12/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1630 13TH AVE
-----------------------------------------------------
City | HUNTINGTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25701-3812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-697-2014
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2585 3RD AVE
-----------------------------------------------------
City | HUNTINGTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25703-1642
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-781-5159
-----------------------------------------------------
Fax | 304-523-8115
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 20669
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------