Provider Demographics
NPI:1669419743
Name:BOOTHBY, MICHAEL H (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:H
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 1:2901 ACME BRICK PLZ
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-4124
Mailing Address - Country:US
Mailing Address - Phone:817-529-1900
Mailing Address - Fax:817-529-1910
Practice Address - Street 1:2901 ACME BRICK PLZ
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-4124
Practice Address - Country:US
Practice Address - Phone:817-529-1900
Practice Address - Fax:817-529-1910
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM1030207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP01010705OtherMEDICARE RAILROAD
TX182488002Medicaid
8V9720OtherBCBS INDIVIDUAL #
0078NROtherBCBS GROUP #
10076286OtherAMERIGROUP MEDICAID
8V9720OtherBCBS INDIVIDUAL #
P00057614OtherMEDICARE RR
P00057614OtherMEDICARE RR
205497151OtherTRICARE