Provider Demographics
NPI:1194915249
Name:BOOTH, BLAKE A (MD)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:A
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 1:1308 BELK BLVD
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-5302
Mailing Address - Country:US
Mailing Address - Phone:662-234-6551
Mailing Address - Fax:662-234-0468
Practice Address - Street 1:1308 BELK BLVD
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5302
Practice Address - Country:US
Practice Address - Phone:662-234-6551
Practice Address - Fax:662-234-0468
Is Sole Proprietor?:No
Enumeration Date:2007-07-25
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS21490207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1000574Medicaid
MS302I184629Medicare PIN