Provider Demographics
NPI:1285639286
Name:BUTLER-POKU, VIDALIA M (MD)
Entity Type:Individual
Prefix:
First Name:VIDALIA
Middle Name:M
Last Name:BUTLER-POKU
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 1:270 E HUNT HWY
Mailing Address - Street 2:10
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85143-4962
Mailing Address - Country:US
Mailing Address - Phone:480-987-5500
Mailing Address - Fax:480-987-5507
Practice Address - Street 1:270 E HUNT HWY
Practice Address - Street 2:10
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85143-4962
Practice Address - Country:US
Practice Address - Phone:480-987-5500
Practice Address - Fax:480-987-5507
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ33705207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ941494Medicaid
PAG85462Medicare UPIN
AZ941494Medicaid
Z62361Medicare PIN