Provider Demographics
NPI:1861460495
Name:BOOTH, JASON (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
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 1824
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52406-1824
Mailing Address - Country:US
Mailing Address - Phone:319-369-4505
Mailing Address - Fax:319-369-4677
Practice Address - Street 1:3933 MOUNT VERNON RD SE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52403-3869
Practice Address - Country:US
Practice Address - Phone:319-363-8148
Practice Address - Fax:319-363-9118
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA33657207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0228692Medicaid
IAI8758Medicare ID - Type Unspecified
IAH04871Medicare UPIN