Provider Demographics
NPI:1215023023
Name:BOOTHBY, RENE A (MD)
Entity Type:Individual
Prefix:DR
First Name:RENE
Middle Name:A
Last Name:BOOTHBY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:SELECT PHYSICIANS ALLIANCE
Mailing Address - Street 2:10002 PRINCESS PALM AVE. STE 332
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33619-8327
Mailing Address - Country:US
Mailing Address - Phone:813-571-7184
Mailing Address - Fax:813-654-4695
Practice Address - Street 1:FLORIDA ENT & ALLERGY
Practice Address - Street 2:5105 N ARMENIA AVE
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33603-1405
Practice Address - Country:US
Practice Address - Phone:813-879-8045
Practice Address - Fax:813-876-6504
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME44406207YX0905X
FLME0044406207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL036277800Medicaid
FL53725Medicare ID - Type UnspecifiedMEDICARE
FL036277800Medicaid