Provider Demographics
NPI:1346425055
Name:BUTLER, JEROME MACK JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:MACK
Last Name:BUTLER
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 QUEENS RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-3253
Mailing Address - Country:US
Mailing Address - Phone:704-333-7376
Mailing Address - Fax:704-333-3397
Practice Address - Street 1:2525 COURT DR
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2140
Practice Address - Country:US
Practice Address - Phone:704-834-2944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-02
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2006-017062085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5908709Medicaid
NC205202OtherMEDCOST
SCN01706Medicaid
NC205202OtherMEDCOST
NC2022206Medicare PIN
NC2022206BMedicare PIN
NC2022206CMedicare PIN
SCN01706Medicaid