Provider Demographics
NPI:1982765152
Name:BOOTH, JACK BRANYON (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:BRANYON
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 1:930 BETHESDA DR. BLDG 4
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-0815
Mailing Address - Country:US
Mailing Address - Phone:740-455-6202
Mailing Address - Fax:
Practice Address - Street 1:930 BETHESDA DR. BLDG 4
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-0815
Practice Address - Country:US
Practice Address - Phone:740-455-6202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-036061207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0274206Medicaid
OH0274206Medicaid
OH0411408Medicare PIN