Provider Demographics
NPI:1184006835
Name:BOOTH, KIERA LYN (MD)
Entity Type:Individual
Prefix:DR
First Name:KIERA
Middle Name:LYN
Last Name:BOOTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KIERA
Other - Middle Name:
Other - Last Name:GOFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1120 W MICHIGAN ST # CL626
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-5209
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1101 PAOLI PIKE
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19380-4642
Practice Address - Country:US
Practice Address - Phone:610-918-2500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-18
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD466761207N00000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN11018459AOtherINDIANA PROFESSIONAL LICENSING
PAMD466761OtherMEDICAL LICENSE