Provider Demographics
NPI:1275515710
Name:BOOTH, MARC ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:ALAN
Last Name:BOOTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:
Practice Address - Street 1:1225 E COOLSPRING AVE STE 1-B
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-6312
Practice Address - Country:US
Practice Address - Phone:219-879-6531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01061093A207W00000X
NC2023-00058207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200527370Medicaid
IL036109395Medicaid
I02693Medicare UPIN
IL9815737OtherBLUE CROSS BLUE SHIELD