1770504631 NPI number — WINFIELD E BUTLIN DPM

Table of content: WINFIELD E BUTLIN DPM (NPI 1770504631)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770504631 NPI number — WINFIELD E BUTLIN DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUTLIN
Provider First Name:
WINFIELD
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
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:
1770504631
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/28/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4535 WINTERS CHAPEL RD
Provider Second Line Business Mailing Address:
STE B
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30360-2705
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-285-7246
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2193 NORTHLAKE PKWY
Provider Second Line Business Practice Location Address:
STE 114
Provider Business Practice Location Address City Name:
TUCKER
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30084-4116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-938-5974
Provider Business Practice Location Address Fax Number:
770-939-7393
Provider Enumeration Date:
07/23/2006

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: 213E00000X , with the licence number:  322 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00006311B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 316899 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 480021837 . This is a "MCR RAILROAD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 517896 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 121113 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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