Provider Demographics
NPI:1518922863
Name:BOOTH, MARK A (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:BOOTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:420 S HILLSDALE ST
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:MI
Mailing Address - Zip Code:49245-1248
Mailing Address - Country:US
Mailing Address - Phone:517-568-4481
Mailing Address - Fax:517-568-3720
Practice Address - Street 1:420 S HILLSDALE ST
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:MI
Practice Address - Zip Code:49245-1248
Practice Address - Country:US
Practice Address - Phone:517-568-4481
Practice Address - Fax:517-568-3720
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301043850207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI080157041OtherRAILROAD MEDICARE
MI080A360590OtherBLUE CROSS BLUE SHIELD
MI103118050Medicaid
MIDA0352OtherRAILROAD MEDICARE GROUP
MIB46342Medicare UPIN
MI233974Medicare Oscar/Certification