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General NPI Number Information
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NPI Number | 1265586317
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Entity Type | Organization
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Legal Business Name | MARILYN J BOOTH MD
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Dates
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Enumeration Date | 01/23/2007
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Last Update Date | 03/23/2008
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Provider Practice Location Address
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Address Line | 3305 19TH AVE
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City | FOREST GROVE
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State | OR
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Zip | 97116-1909
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Country | US
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Telephone | 503-357-7194
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Fax | 503-357-5735
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Provider Business Mailing Address
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Address Line | 3305 19TH AVE
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City | FOREST GROVE
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State | OR
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Zip | 97116-1909
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Country | US
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Telephone | 503-357-7194
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Fax | 503-357-5735
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Authorized Official
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Title or Position | OWNER
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Name | MARILYN J BOOTH
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Credential | MD
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Telephone | 503-357-7194
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | MD13329
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License Number State | OR
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