Provider Demographics
NPI:1558387696
Name:BOOTH, KELEY JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:KELEY
Middle Name:JOHN
Last Name:BOOTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 6491
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73070-6491
Mailing Address - Country:US
Mailing Address - Phone:405-947-8585
Mailing Address - Fax:405-948-6507
Practice Address - Street 1:4401 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73109-3413
Practice Address - Country:US
Practice Address - Phone:918-664-9892
Practice Address - Fax:918-664-2521
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK22940207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200087480AMedicaid
TX433243ZPYYOtherMEDICARE
OKOK401637Medicare PIN
TX433243ZPYYOtherMEDICARE