Provider Demographics
NPI:1376548354
Name:BOOTHBY, RICHARD A (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
Last Name:BOOTHBY
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:PO BOX 780125
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-0125
Mailing Address - Country:US
Mailing Address - Phone:804-922-4844
Mailing Address - Fax:
Practice Address - Street 1:1001 E LEIGH ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-5004
Practice Address - Country:US
Practice Address - Phone:804-828-9080
Practice Address - Fax:804-828-3891
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0038681207VX0201X
VT042-0014870207VX0201X
VA0101272965207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL376537700Medicaid
FLA65164Medicare UPIN
FL3439930OtherAETNA OTHER PROVIDER NUM
FL4275842OtherAETNA HMO PROVIDER NUMBER
FLP00470763Medicare PIN
FL716396OtherFIRST HEALTH PROVIDER NUM
FL10788OtherBCBS PROVIDER NUMBER
FL1734502-008OtherCIGNA PROVIDER NUMBER
FL10788TMedicare ID - Type Unspecified
FL068770700Medicaid