Provider Demographics
NPI:1174552830
Name:BOOTH, JEFFREY E (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:E
Last Name:BOOTH
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:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-387-7125
Mailing Address - Fax:801-387-7130
Practice Address - Street 1:4403 HARRISON BLVD
Practice Address - Street 2:STE 3650
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-3271
Practice Address - Country:US
Practice Address - Phone:801-387-7125
Practice Address - Fax:801-387-7130
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2022-04-29
Deactivation Date:2022-01-31
Deactivation Code:
Reactivation Date:2022-04-29
Provider Licenses
StateLicense IDTaxonomies
UT771607311205207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D07288Medicare UPIN
000000777Medicare PIN
000063078Medicare PIN