Provider Demographics
NPI:1083694970
Name:BOOTH, RICHARD JR (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:BOOTH
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2585 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25703-1642
Mailing Address - Country:US
Mailing Address - Phone:304-781-5159
Mailing Address - Fax:304-523-8115
Practice Address - Street 1:1630 13TH AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-3812
Practice Address - Country:US
Practice Address - Phone:304-697-2014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV20669207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVP00058440OtherRR MEDICARE
KY64051667Medicaid
WV000000235271OtherANTHEM
WV1083694970Medicaid
WV001709560OtherMT. STATE
OH2342138Medicaid
WV1808365000Medicaid
WV000000235271OtherANTHEM
WVP00058440OtherRR MEDICARE