Provider Demographics
NPI:1275510810
Name:BUTCHER, JOHN T (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:T
Last Name:BUTCHER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 45443
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84145-0443
Mailing Address - Country:US
Mailing Address - Phone:904-202-1032
Mailing Address - Fax:904-376-4107
Practice Address - Street 1:13001 ATLANTIC BLVD STE 100
Practice Address - Street 2:CREDENTIALING DEPARTMENT
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-7126
Practice Address - Country:US
Practice Address - Phone:904-221-0264
Practice Address - Fax:904-221-5141
Is Sole Proprietor?:No
Enumeration Date:2005-12-26
Last Update Date:2018-12-31
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME83914207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL080182537OtherRR MEDICARE
G74693Medicare UPIN
FL28096ZMedicare PIN