Provider Demographics
NPI:1225057011
Name:BOOTH, MARILYN J (MD)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:J
Last Name:BOOTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3305 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:FOREST GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97116-1909
Mailing Address - Country:US
Mailing Address - Phone:503-357-7194
Mailing Address - Fax:503-357-5735
Practice Address - Street 1:3305 19TH AVE
Practice Address - Street 2:
Practice Address - City:FOREST GROVE
Practice Address - State:OR
Practice Address - Zip Code:97116-1909
Practice Address - Country:US
Practice Address - Phone:503-357-7194
Practice Address - Fax:503-357-5735
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2013-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD13329207Q00000X, 207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR020711000OtherBC
OR26676-7Medicaid
ORC92249Medicare UPIN
OR26676-7Medicaid