Basic Information
| Provider Information | |||||||||
| NPI: | 1659020949 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOOTH | ||||||||
| FirstName: | MITCHELL | ||||||||
| MiddleName: | BRYAN | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2307 W JOYLI CIR | ||||||||
| Address2: | |||||||||
| City: | WEST JORDAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840887652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3852286548 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1719 E 19TH AVE | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802181235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7207546000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2022 | ||||||||
| LastUpdateDate: | 03/22/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.