Provider Demographics
NPI:1710985726
Name:BOOTH, EDGAR (MD)
Entity Type:Individual
Prefix:
First Name:EDGAR
Middle Name:
Last Name:BOOTH
Suffix:
Gender:M
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:PO BOX 1169
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84011-1169
Mailing Address - Country:US
Mailing Address - Phone:801-296-2113
Mailing Address - Fax:801-296-1715
Practice Address - Street 1:3725 W 4100 S
Practice Address - Street 2:STE 102
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84120-5417
Practice Address - Country:US
Practice Address - Phone:801-652-4466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-13
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT17898512052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD0432Medicaid
ID805426200Medicaid
WY114168600Medicaid