Provider Demographics
NPI:1184852717
Name:BOOTHE, MICHAEL C (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:C
Last Name:BOOTHE
Suffix:
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 1:2819 MEDLIN DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76015-2329
Mailing Address - Country:US
Mailing Address - Phone:817-303-6800
Mailing Address - Fax:817-303-6832
Practice Address - Street 1:2819 MEDLIN DR
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76015-2329
Practice Address - Country:US
Practice Address - Phone:817-303-6800
Practice Address - Fax:817-303-6832
Is Sole Proprietor?:No
Enumeration Date:2009-06-22
Last Update Date:2013-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH6063207QB0002X, 207V00000X
TXH 6063208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No207QB0002XAllopathic & Osteopathic PhysiciansFamily MedicineObesity Medicine
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX259854YLB6Medicare PIN