Basic Information
| Provider Information | |||||||||
| NPI: | 1326045048 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUTLER | ||||||||
| FirstName: | ALLEN | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2406 LIGHTHOUSE MANOR DR | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305017401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705364352 | ||||||||
| FaxNumber: | 7705328165 | ||||||||
| Practice Location | |||||||||
| Address1: | 2406 LIGHTHOUSE MANOR DR | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305017401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705364352 | ||||||||
| FaxNumber: | 7705328165 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2005 | ||||||||
| LastUpdateDate: | 11/02/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 14873R | LA | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207Y00000X | 52260 | GA | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 1151262 | 05 | LA | MEDICAID |