Provider Demographics
NPI:1457519266
Name:BOOTHBY, LESLIE BRADFORD (MD)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:BRADFORD
Last Name:BOOTHBY
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 1:3851 ROGER BROOKE DR
Mailing Address - Street 2:MCHE-ER
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78234-4501
Mailing Address - Country:US
Mailing Address - Phone:210-916-0808
Mailing Address - Fax:
Practice Address - Street 1:3851 ROGER BROOKE DR
Practice Address - Street 2:MCHE-ER
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78234-4501
Practice Address - Country:US
Practice Address - Phone:210-916-0808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-29
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171000000X
TXQ0010207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No171000000XOther Service ProvidersMilitary Health Care Provider