Provider Demographics
NPI:1760426902
Name:JACKSON-BOOTH, PETA-GAY (MD)
Entity Type:Individual
Prefix:DR
First Name:PETA-GAY
Middle Name:
Last Name:JACKSON-BOOTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PETA-GAY
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2200 KERNAN DRIVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21207
Mailing Address - Country:US
Mailing Address - Phone:410-448-6283
Mailing Address - Fax:410-448-6277
Practice Address - Street 1:2200 KERNAN DRIVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21207
Practice Address - Country:US
Practice Address - Phone:410-448-6283
Practice Address - Fax:410-448-6277
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0052122207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD110229896Medicaid
MD019M-744EMedicare ID - Type Unspecified
MDH37022Medicare UPIN