Provider Demographics
NPI:1588600092
Name:BOOTHBY, CHARLES MOORE (DO)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:MOORE
Last Name:BOOTHBY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 25513
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33622-5513
Mailing Address - Country:US
Mailing Address - Phone:727-823-2188
Mailing Address - Fax:727-828-0723
Practice Address - Street 1:3890 TAMPA RD
Practice Address - Street 2:SUITE 201
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684-3676
Practice Address - Country:US
Practice Address - Phone:727-781-3111
Practice Address - Fax:727-781-3113
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS45982083P0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL069165800Medicaid
E32267Medicare UPIN
FL82569TMedicare PIN