Provider Demographics
NPI:1093913212
Name:BUTLER, ALLISON DASTA (MD)
Entity Type:Individual
Prefix:
First Name:ALLISON
Middle Name:DASTA
Last Name:BUTLER
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 1:1075 OAKLEAF PLANTATION PKWY
Mailing Address - Street 2:SUITE #108
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-3624
Mailing Address - Country:US
Mailing Address - Phone:904-282-4565
Mailing Address - Fax:904-282-4225
Practice Address - Street 1:1075 OAKLEAF PLANTATION PKWY
Practice Address - Street 2:SUITE #108
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32065-3624
Practice Address - Country:US
Practice Address - Phone:904-282-4565
Practice Address - Fax:904-282-4225
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2009-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 97725207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAI751ZMedicare PIN