Provider Demographics
NPI:1023196979
Name:BUTKIEWICZ, ELISE (MD)
Entity Type:Individual
Prefix:DR
First Name:ELISE
Middle Name:
Last Name:BUTKIEWICZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 416457
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-6457
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:33 OVERLOOK RD
Practice Address - Street 2:103
Practice Address - City:SUMMIT
Practice Address - State:NJ
Practice Address - Zip Code:07901-3570
Practice Address - Country:US
Practice Address - Phone:908-522-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06301400207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ953197N2ZOtherBCBS
NJ7297904Medicaid
NJ7297904Medicaid
NJG53108Medicare UPIN