Provider Demographics
NPI:1104822832
Name:BOOTH, KEVIN CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:CHARLES
Last Name:BOOTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:696 SAN RAMON VALLEY BLVD # 372
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94526-4022
Mailing Address - Country:US
Mailing Address - Phone:925-469-3120
Mailing Address - Fax:925-924-1769
Practice Address - Street 1:5725 W LAS POSITAS BLVD
Practice Address - Street 2:STE 200
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94588-4007
Practice Address - Country:US
Practice Address - Phone:925-469-6274
Practice Address - Fax:925-924-1769
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG77956207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G66858Medicare UPIN