Provider Demographics
NPI:1639137268
Name:BUTLER, DIANE ARLENE (MD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:ARLENE
Last Name:BUTLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:ARLENE
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:6681 RIDGE RD
Mailing Address - Street 2:#205
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44129-5713
Mailing Address - Country:US
Mailing Address - Phone:440-842-1121
Mailing Address - Fax:440-842-5676
Practice Address - Street 1:6681 RIDGE RD
Practice Address - Street 2:#205
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44129-5713
Practice Address - Country:US
Practice Address - Phone:440-842-1121
Practice Address - Fax:440-842-5676
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35043685208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0692880Medicaid
OH000000139981OtherANTHEM
OH341834105031OtherCARE SOURCE
OH341834105031OtherCARE SOURCE
OHBU0780512Medicare ID - Type Unspecified