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General NPI Number Information
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NPI Number | 1275515710
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Entity Type | Individual
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Provider Name | MARC ALAN BOOTH MD
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Gender | Male
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Dates
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Enumeration Date | 11/18/2005
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Last Update Date | 02/13/2023
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Provider Practice Location Address
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Address Line | 1225 E COOLSPRING AVE STE 1-B
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City | MICHIGAN CITY
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State | IN
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Zip | 46360-6312
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Country | US
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Telephone | 219-879-6531
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 781076
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City | DETROIT
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State | MI
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Zip | 48278-1076
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Country | US
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Telephone | 317-528-4800
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | 01061093A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | 2023-00058
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License Number State | NC
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