Provider Demographics
NPI:1841237666
Name:BOOTH, SCOTT LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:LEE
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 1:121 SOTOYOME ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4823
Mailing Address - Country:US
Mailing Address - Phone:707-546-4062
Mailing Address - Fax:707-525-4097
Practice Address - Street 1:121 SOTOYOME ST
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4823
Practice Address - Country:US
Practice Address - Phone:707-546-4062
Practice Address - Fax:707-525-4097
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG590352085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G590350Medicaid
CAE37952Medicare UPIN
CA00G590350Medicare ID - Type UnspecifiedINDIVIDUAL PROVIDER ID