Basic Information
Provider Information | |||||||||
NPI: | 1851475073 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BUTLER | ||||||||
FirstName: | SAMANTHA | ||||||||
MiddleName: | LYN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BUTLER-GARCIA | ||||||||
OtherFirstName: | SAMANTHA | ||||||||
OtherMiddleName: | LYN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | BROOKE ARMY MEDICAL CENTER | ||||||||
Address2: | 3551 ROGER BROOKE DRIVE | ||||||||
City: | FT SAM HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 78234 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2109163307 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3551 ROGER BROOKE DR DEPT OF | ||||||||
Address2: |   | ||||||||
City: | FORT SAM HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 782344504 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2109163307 | ||||||||
FaxNumber: | 2109163235 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/24/2006 | ||||||||
LastUpdateDate: | 05/15/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/15/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZC0500X | ME 109693 | FL | N |   | Allopathic & Osteopathic Physicians | Pathology | Cytopathology | 207ZP0102X | ME 109693 | FL | Y |   | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
No ID Information.