1104925205 NPI number — MICHAEL LAWRENCE BUTERA M.D.

Table of content: (NPI 1770265860)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104925205 NPI number — MICHAEL LAWRENCE BUTERA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUTERA
Provider First Name:
MICHAEL
Provider Middle Name:
LAWRENCE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104925205
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/17/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1009
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRING VALLEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91979-1009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-508-0908
Provider Business Mailing Address Fax Number:
619-693-3242

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6699 ALVARADO RD STE 2309
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92120-5241
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-286-8803
Provider Business Practice Location Address Fax Number:
619-286-2344
Provider Enumeration Date:
09/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RI0200X , with the licence number:  G70238 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00G702380 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: WG70238C . This is a "MEDICARE PTAN" identifier . This identifiers is of the category "OTHER".




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