Provider Demographics
NPI:1659020949
Name:BOOTH, MITCHELL BRYAN (DPM)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:BRYAN
Last Name:BOOTH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2307 W JOYLI CIR
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-7652
Mailing Address - Country:US
Mailing Address - Phone:385-228-6548
Mailing Address - Fax:
Practice Address - Street 1:1719 E 19TH AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80218-1235
Practice Address - Country:US
Practice Address - Phone:720-754-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-22
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program