Provider Demographics
NPI:1255318721
Name:BUTLER, STEPHEN RUSSELL (DO)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:RUSSELL
Last Name:BUTLER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:168 COTTONTAIL DR
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:RI
Mailing Address - Zip Code:02871-5155
Mailing Address - Country:US
Mailing Address - Phone:401-619-1358
Mailing Address - Fax:
Practice Address - Street 1:39 FAUNCE CORNER RD
Practice Address - Street 2:
Practice Address - City:DARTMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02747-4202
Practice Address - Country:US
Practice Address - Phone:508-996-3311
Practice Address - Fax:508-997-5352
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA154055207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3170896Medicaid
MA9703705Medicaid
M21357Medicare ID - Type Unspecified
G61026Medicare UPIN
MA9703705Medicaid