Basic Information
| Provider Information | |||||||||
| NPI: | 1992096986 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOOTH | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | C. | ||||||||
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| Credential: | LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12815 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731572815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056045613 | ||||||||
| FaxNumber: | 4056013750 | ||||||||
| Practice Location | |||||||||
| Address1: | 3601 N MAY AVE | ||||||||
| Address2: | SUITE C | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731126641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056045613 | ||||||||
| FaxNumber: | 4056013750 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2011 | ||||||||
| LastUpdateDate: | 04/25/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 242T00000X | 57 | OK | Y | Technologists, Technicians & Other Technical Service Providers | Perfusionist |
No ID Information.