Provider Demographics
NPI:1023016649
Name:BOOTH, ROBERT L JR (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:L
Last Name:BOOTH
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:3355 GLENDALE AVE FL 3
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-2426
Mailing Address - Country:US
Mailing Address - Phone:419-383-3472
Mailing Address - Fax:419-383-6130
Practice Address - Street 1:3000 ARLINGTON AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614-2595
Practice Address - Country:US
Practice Address - Phone:419-383-3472
Practice Address - Fax:419-383-6130
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2019-01-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OH35053764207ZH0000X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0815238Medicaid
OHBO0687744Medicare ID - Type Unspecified
OH0815238Medicaid