Provider Demographics
NPI:1063736056
Name:BOOHER, KATELYN JEAN (DO)
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:JEAN
Last Name:BOOHER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45435-0001
Mailing Address - Country:US
Mailing Address - Phone:937-245-7100
Mailing Address - Fax:937-245-7999
Practice Address - Street 1:1222 S PATTERSON BLVD
Practice Address - Street 2:STE 220
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45402-2684
Practice Address - Country:US
Practice Address - Phone:937-223-5350
Practice Address - Fax:937-224-3112
Is Sole Proprietor?:No
Enumeration Date:2010-03-18
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH35-011518207RI0200X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0121909Medicaid