Provider Demographics
NPI:1649711904
Name:BOOTHE, WILLIAM DAVID JR (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:DAVID
Last Name:BOOTHE
Suffix:JR
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 1:4608 93RD ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79424-5012
Mailing Address - Country:US
Mailing Address - Phone:806-789-0553
Mailing Address - Fax:
Practice Address - Street 1:3601 4TH ST STOP 6211
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79430
Practice Address - Country:US
Practice Address - Phone:806-743-2978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-19
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR9043207N00000X, 1744R1102X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744R1102XOther Service ProvidersSpecialistResearch Study
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program