Provider Demographics
NPI:1437141314
Name:BOOTH, KELLY A (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1054 BURRAGE RD NE
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2910
Practice Address - Country:US
Practice Address - Phone:704-403-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2023-12-18
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
NC9700449207V00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890144VMedicaid
NC232009OtherMEDICARE PIN GROUP
NC232009OtherMEDICARE PIN GROUP
NCG53125Medicare UPIN
NC2073249Medicare PIN