Provider Demographics
NPI:1619908175
Name:BUTLER, JEFFREY DWAYNE (DO)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:DWAYNE
Last Name:BUTLER
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 1:2100 POWELL ST
Mailing Address - Street 2:SUITE 900
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-1826
Mailing Address - Country:US
Mailing Address - Phone:510-350-2600
Mailing Address - Fax:510-879-9059
Practice Address - Street 1:2615 EYE ST
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93301-2006
Practice Address - Country:US
Practice Address - Phone:661-395-3000
Practice Address - Fax:661-323-4703
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8956207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA020A89560Medicare PIN
H05378Medicare UPIN