Provider Demographics
NPI:1639129422
Name:BUTLER, TREY M (MD)
Entity Type:Individual
Prefix:
First Name:TREY
Middle Name:M
Last Name:BUTLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 MCCLELLAND BLVD
Mailing Address - Street 2:BLDG. C, SUITE 304
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-1623
Mailing Address - Country:US
Mailing Address - Phone:417-781-9000
Mailing Address - Fax:417-781-5704
Practice Address - Street 1:2700 MCCLELLAND BLVD
Practice Address - Street 2:BLDG. C, SUITE 304
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-1623
Practice Address - Country:US
Practice Address - Phone:417-781-9000
Practice Address - Fax:417-781-5704
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO100647207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO474892OtherANTHEM BC MISSOURI
KS700845OtherBLUECROSS KANSAS ID#
OK100119790AMedicaid
KS100147330AMedicaid
MO206735706Medicaid
OK100119790AMedicaid
MO180019707Medicare ID - Type UnspecifiedMEDICARE RAILROAD ID #
MOF62283Medicare UPIN