Provider Demographics
NPI:1639127996
Name:BUTLER, DAVID ALLEN (DO)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:ALLEN
Last Name:BUTLER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 HARBOR BLVD STE 4
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-5038
Mailing Address - Country:US
Mailing Address - Phone:941-629-3500
Mailing Address - Fax:941-629-3100
Practice Address - Street 1:2400 HARBOR BLVD STE 4
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-5038
Practice Address - Country:US
Practice Address - Phone:941-629-3500
Practice Address - Fax:941-629-3100
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2057207Q00000X
FLOS10915208M00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2516325Medicaid
WV3810001614Medicaid
001859054OtherBLUE CROSS/BLUE SHIELD
BB8906109OtherDEA
BU4183871Medicare PIN
OH2516325Medicaid
FLDB010ZMedicare PIN