Provider Demographics
NPI:1700128154
Name:BOOTHE, DUSTIN LEE (MD)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:LEE
Last Name:BOOTHE
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 1:2005 MEANDER RD
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CO
Mailing Address - Zip Code:80550-4628
Mailing Address - Country:US
Mailing Address - Phone:425-773-5011
Mailing Address - Fax:
Practice Address - Street 1:1800 15TH ST STE A
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631
Practice Address - Country:US
Practice Address - Phone:970-820-5941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-25
Last Update Date:2018-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.00602912085R0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program