Provider Demographics
NPI:1194749473
Name:BOOTH, HOLLY RENEE (OD)
Entity type:Individual
Prefix:DR
First Name:HOLLY
Middle Name:RENEE
Last Name:BOOTH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1502 CUMBERLAND AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLESBORO
Mailing Address - State:KY
Mailing Address - Zip Code:40965-1223
Mailing Address - Country:US
Mailing Address - Phone:606-248-0932
Mailing Address - Fax:606-248-1384
Practice Address - Street 1:1502 CUMBERLAND AVE
Practice Address - Street 2:
Practice Address - City:MIDDLESBORO
Practice Address - State:KY
Practice Address - Zip Code:40965-1223
Practice Address - Country:US
Practice Address - Phone:606-248-0932
Practice Address - Fax:606-248-1384
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2016-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1673DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1673DTOtherSTATE LICENSE NUMBER
1231987OtherCHA PROVIDER NUMBER
VA010332605Medicaid
134506OtherVISION CARE PIN NUMBER
KY000000492097OtherANTHEM PIN NUMBER
KY1673DTOtherSTATE LICENSE NUMBER
KY000000492097OtherANTHEM PIN NUMBER