Provider Demographics
NPI:1578585014
Name:CENTRAL LEATHERSTOCKING MEDICAL, PLLC
Entity Type:Organization
Organization Name:CENTRAL LEATHERSTOCKING MEDICAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:C
Authorized Official - Last Name:BOOTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-822-3200
Mailing Address - Street 1:943 US HIGHWAY 20
Mailing Address - Street 2:
Mailing Address - City:WEST WINFIELD
Mailing Address - State:NY
Mailing Address - Zip Code:13491
Mailing Address - Country:US
Mailing Address - Phone:315-822-3200
Mailing Address - Fax:315-822-5193
Practice Address - Street 1:943 US HIGHWAY 20
Practice Address - Street 2:
Practice Address - City:WEST WINFIELD
Practice Address - State:NY
Practice Address - Zip Code:13491-1920
Practice Address - Country:US
Practice Address - Phone:315-822-3200
Practice Address - Fax:315-822-5193
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY175678207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02702638Medicaid
NYBA0541Medicare ID - Type Unspecified