Provider Demographics
NPI:1417941873
Name:BUTLER, WELDON FRED (MD)
Entity Type:Individual
Prefix:
First Name:WELDON
Middle Name:FRED
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 1:700 DOTSY AVE
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79763-4238
Mailing Address - Country:US
Mailing Address - Phone:432-333-3295
Mailing Address - Fax:432-333-8840
Practice Address - Street 1:700 DOTSY AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79763-4238
Practice Address - Country:US
Practice Address - Phone:432-333-3295
Practice Address - Fax:432-333-8840
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH0224208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
C14024Medicare UPIN
00QX61Medicare ID - Type Unspecified