Provider Demographics
NPI:1093786162
Name:BUTLER, BRIAN (DPM)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:BUTLER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 SAGAMORE RD
Mailing Address - Street 2:
Mailing Address - City:BRONXVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:10708-1506
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 HANSON PL
Practice Address - Street 2:SUITE 1215
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11243-2907
Practice Address - Country:US
Practice Address - Phone:718-230-4844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN003220174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00703993Medicaid
NYT51068Medicare UPIN
NYP35671Medicare ID - Type Unspecified
NY00703993Medicaid
NY4704220001Medicare NSC