Provider Demographics
NPI:1265810261
Name:WILLIAM DAVID BOOTHE MD PA
Entity type:Organization
Organization Name:WILLIAM DAVID BOOTHE MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LUANN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOOTHE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-797-6697
Mailing Address - Street 1:4020 21ST ST STE 3
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-1126
Mailing Address - Country:US
Mailing Address - Phone:806-797-6697
Mailing Address - Fax:806-797-6849
Practice Address - Street 1:4020 21ST ST STE 3
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1126
Practice Address - Country:US
Practice Address - Phone:806-797-6697
Practice Address - Fax:806-797-6849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-11
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF3769207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX122946003Medicaid
TXB21391Medicare UPIN