Basic Information
| Provider Information | |||||||||
| NPI: | 1538141528 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUTLER | ||||||||
| FirstName: | ROGER | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7808 CLODUS FIELDS DR | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752512206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727701032 | ||||||||
| FaxNumber: | 9727701032 | ||||||||
| Practice Location | |||||||||
| Address1: | 7808 CLODUS FIELDS DR | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752512206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9725667260 | ||||||||
| FaxNumber: | 9725666237 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2005 | ||||||||
| LastUpdateDate: | 02/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 34096 | TX | N | Behavioral Health & Social Service Providers | Psychologist | 2084P0800X | G9839 | TX | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 122603702 | 05 | TX | MEDICAID | 122603705 | 05 | TX | MEDICAID |