Provider Demographics
NPI:1225246622
Name:BUTLER, STACY COLOMBO (MD)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:COLOMBO
Last Name:BUTLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2512 OLD TRINITY WAY
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76116-0517
Mailing Address - Country:US
Mailing Address - Phone:817-346-5336
Mailing Address - Fax:817-346-5366
Practice Address - Street 1:6100 HARRIS PKWY STE 140
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-4130
Practice Address - Country:US
Practice Address - Phone:817-346-5336
Practice Address - Fax:817-346-5366
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN2037207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
8AG791OtherBC/BS
TX205438901Medicaid
TX8L16657Medicare PIN