Provider Demographics
NPI:1427021559
Name:BUTVILAS, KEITH (DO)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:
Last Name:BUTVILAS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1235 E CHEROKEE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-2203
Mailing Address - Country:US
Mailing Address - Phone:417-820-2115
Mailing Address - Fax:
Practice Address - Street 1:1235 E CHEROKEE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2203
Practice Address - Country:US
Practice Address - Phone:417-820-2115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP60128085207P00000X
IA3697207P00000X
IL036100436207P00000X
MO2019033217207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1571745Medicaid
IL0181OtherJOHN DEERE
99321OtherBCWELLMARK WEST
IL0571745Medicaid
MT1427021559Medicaid
IA1427021559OtherBLUE SHIELD
WA1427021559Medicaid
IA1427021559Medicaid
362739299-001OtherTRICARE/HEALTH NET
99320OtherBCWELLMARK 7TH
MT1427021559Medicaid
IL0571745Medicaid
IA1427021559OtherBLUE SHIELD
IA1427021559Medicaid
WAG8891348Medicare PIN