Provider Demographics
NPI:1316562515
Name:BOOTH, JERAD ROLAND (DPM)
Entity Type:Individual
Prefix:DR
First Name:JERAD
Middle Name:ROLAND
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 1:22201 MOROSS RD STE 250
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48236-2175
Mailing Address - Country:US
Mailing Address - Phone:313-343-3423
Mailing Address - Fax:313-343-3401
Practice Address - Street 1:2007 E 14 MILE RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-5905
Practice Address - Country:US
Practice Address - Phone:586-244-9699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-12
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901400501213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty