Provider Demographics
NPI:1659020949
Name:BOOTH, MITCHELL BRYAN (DPM)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:BRYAN
Last Name:BOOTH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2307 W JOYLI CIR
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-7652
Mailing Address - Country:US
Mailing Address - Phone:385-228-6548
Mailing Address - Fax:
Practice Address - Street 1:1904 E BARNETT RD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8262
Practice Address - Country:US
Practice Address - Phone:541-776-3338
Practice Address - Fax:541-776-4979
Is Sole Proprietor?:No
Enumeration Date:2022-03-22
Last Update Date:2025-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP224114213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery