Provider Demographics
NPI:1588018170
Name:BOOTHMAN, PETER (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:BOOTHMAN
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Mailing Address - Street 1:1618 S MILLENIUM WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-6457
Mailing Address - Country:US
Mailing Address - Phone:208-884-3376
Mailing Address - Fax:208-884-0858
Practice Address - Street 1:1618 S MILLENIUM WAY STE 100
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6457
Practice Address - Country:US
Practice Address - Phone:208-884-3376
Practice Address - Fax:208-884-0858
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-20
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDM-17515207ND0101X
ALMD.36224207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery