Provider Demographics
NPI:1194288415
Name:BOOTH, CORTNEY RAYE (DO)
Entity type:Individual
Prefix:
First Name:CORTNEY
Middle Name:RAYE
Last Name:BOOTH
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:PO BOX 744786
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-4786
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:620 SUMMIT CROSSING PL STE 108A
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2189
Practice Address - Country:US
Practice Address - Phone:704-671-5313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-12
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC90015207V00000X
NC00646207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR920714654Medicaid