Provider Demographics
NPI:1366487225
Name:BUTLER, DERRICK LAMONT (MD)
Entity Type:Individual
Prefix:DR
First Name:DERRICK
Middle Name:LAMONT
Last Name:BUTLER
Suffix:
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 1:3834 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90062-1104
Mailing Address - Country:US
Mailing Address - Phone:323-730-1920
Mailing Address - Fax:323-730-1504
Practice Address - Street 1:3834 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90062-1104
Practice Address - Country:US
Practice Address - Phone:323-730-1920
Practice Address - Fax:323-730-1504
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA67268207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A672680Medicaid
CAWA67268EMedicare PIN
CAWA67268Medicare PIN
CAH01421Medicare UPIN
CA00A672680Medicaid