Provider Demographics
NPI:1417991126
Name:BUTTLES, JASON R (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:R
Last Name:BUTTLES
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:FILE NUMBER 54701
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-0001
Mailing Address - Country:US
Mailing Address - Phone:909-558-3111
Mailing Address - Fax:909-558-3905
Practice Address - Street 1:11370 ANDERSON ST
Practice Address - Street 2:SUITE B-100
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3450
Practice Address - Country:US
Practice Address - Phone:909-558-2848
Practice Address - Fax:909-558-3905
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA89208208000000X
TXM7076208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8V0289OtherBCBS
TX0073PTOtherBCBS
TX8AA311OtherBCBS