Provider Demographics
NPI:1669452884
Name:BOOTH, SALLY A (MD)
Entity Type:Individual
Prefix:DR
First Name:SALLY
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 1:12050 N MICHIGAN RD
Mailing Address - Street 2:
Mailing Address - City:ZIONSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46077-8782
Mailing Address - Country:US
Mailing Address - Phone:317-848-2427
Mailing Address - Fax:317-848-2434
Practice Address - Street 1:12050 N MICHIGAN RD
Practice Address - Street 2:
Practice Address - City:ZIONSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46077-8782
Practice Address - Country:US
Practice Address - Phone:317-848-2427
Practice Address - Fax:317-848-2434
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME142799207N00000X
IN01042816A207ND0101X, 207NS0135X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000375169OtherANTHEM PIN
INF07729Medicare UPIN
IN000000375169OtherANTHEM PIN