Provider Demographics
NPI:1093151086
Name:BOOTHE, JASON ADRIAN (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:ADRIAN
Last Name:BOOTHE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-0588
Mailing Address - Fax:704-384-0580
Practice Address - Street 1:6324 FAIRVIEW RD STE 201
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-4278
Practice Address - Country:US
Practice Address - Phone:704-384-0588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2016-00166207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC193050OtherRTL RESIDENT TRAINING LICENSE NUMBER
NC2016-00166OtherNORTH CAROLINA MEDICAL BOARD
NC2016-00166OtherNORTH CAROLINA MEDICAL BOARD