Basic Information
| Provider Information | |||||||||
| NPI: | 1255310710 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOOTON | ||||||||
| FirstName: | DEREK | ||||||||
| MiddleName: | V | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 17037 | ||||||||
| Address2: | |||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618037037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008976169 | ||||||||
| FaxNumber: | 8008976170 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 29TH AVE N STE 202 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372031448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153274304 | ||||||||
| FaxNumber: | 6153277940 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2006 | ||||||||
| LastUpdateDate: | 11/29/2018 | ||||||||
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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 | 207L00000X | 58170 | TN | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 036102911 | IL | N | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 036102911 | 01 | IL | BC OF IL | OTHER | 036102911 | 05 | IL | MEDICAID |