Provider Demographics
NPI:1144668377
Name:CLAYBURN C. BOOTH, M.D., P.C.
Entity type:Organization
Organization Name:CLAYBURN C. BOOTH, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CLAYBURN
Authorized Official - Middle Name:C
Authorized Official - Last Name:BOOTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-751-6179
Mailing Address - Street 1:2861 W LAKE RD
Mailing Address - Street 2:P.O. BOX 856
Mailing Address - City:WILSON
Mailing Address - State:NY
Mailing Address - Zip Code:14172-9626
Mailing Address - Country:US
Mailing Address - Phone:716-751-6179
Mailing Address - Fax:
Practice Address - Street 1:5300 MILITARY RD
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:NY
Practice Address - Zip Code:14092-1903
Practice Address - Country:US
Practice Address - Phone:716-297-4800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-10
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY091157207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYC4955Medicare UPIN