Provider Demographics
NPI:1467444844
Name:BUTLER, KIM JOHNSON (OD)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:JOHNSON
Last Name:BUTLER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1273 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92021-4902
Mailing Address - Country:US
Mailing Address - Phone:619-579-2345
Mailing Address - Fax:619-579-0876
Practice Address - Street 1:1273 BROADWAY
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92021-4902
Practice Address - Country:US
Practice Address - Phone:619-579-2345
Practice Address - Fax:619-579-0876
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-22
Last Update Date:2009-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT6405TPA152W00000X, 152WC0802X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0064050Medicaid
CASD0064051Medicaid
OP6405Medicare PIN
0206600001Medicare NSC
T10313Medicare UPIN