Provider Demographics
NPI:1093788523
Name:BOOTH, DAVID G (DO)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:G
Last Name:BOOTH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 VETERANS MEMORIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:EUPORA
Mailing Address - State:MS
Mailing Address - Zip Code:39744-2064
Mailing Address - Country:US
Mailing Address - Phone:662-258-7200
Mailing Address - Fax:
Practice Address - Street 1:1301 VETERANS MEMORIAL BLVD
Practice Address - Street 2:
Practice Address - City:EUPORA
Practice Address - State:MS
Practice Address - Zip Code:39744-2064
Practice Address - Country:US
Practice Address - Phone:662-258-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13719207Q00000X
NC2014-00095207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1093788523Medicaid
MS00113548Medicaid
NC1093788523Medicaid
NC1093788523Medicaid