Provider Demographics
NPI:1770452021
Name:BOOTH, MARVIN
Entity type:Individual
Prefix:
First Name:MARVIN
Middle Name:
Last Name:BOOTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14107 PACIFIC AVE S
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98444-4622
Mailing Address - Country:US
Mailing Address - Phone:253-285-0821
Mailing Address - Fax:206-659-7691
Practice Address - Street 1:14107 PACIFIC AVE S
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98444-4622
Practice Address - Country:US
Practice Address - Phone:253-285-0821
Practice Address - Fax:206-659-7691
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-04
Last Update Date:2025-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty