Provider Demographics
NPI:1225072598
Name:BOOTH, CAROL WITCRAFT (MD)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:WITCRAFT
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 1:1875 DEMPSTER ST
Mailing Address - Street 2:SUITE 310
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1186
Mailing Address - Country:US
Mailing Address - Phone:847-723-7705
Mailing Address - Fax:847-723-8675
Practice Address - Street 1:1875 DEMPSTER ST
Practice Address - Street 2:SUITE 310
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1186
Practice Address - Country:US
Practice Address - Phone:847-723-7705
Practice Address - Fax:847-723-8675
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2009-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036042710207SG0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
Provider Identifiers
StateIdentifier IDID TypeIssuer
460002585OtherRR MED PIN
IL036042710Medicaid
C19354OtherRR MED GROUP
L68877Medicare PIN
C19354OtherRR MED GROUP
650950Medicare ID - Type Unspecified
460002585OtherRR MED PIN