Provider Demographics
NPI:1639154495
Name:BUTTERFIELD, JACK (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:BUTTERFIELD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 BETHESDA DR
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-1800
Mailing Address - Country:US
Mailing Address - Phone:740-454-4651
Mailing Address - Fax:740-454-4653
Practice Address - Street 1:167 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:OH
Practice Address - Zip Code:43777-1284
Practice Address - Country:US
Practice Address - Phone:740-697-7373
Practice Address - Fax:740-697-7683
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35045078207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH080002140OtherMEDICARE RAILROAD
OH000000019419OtherANTHEM PIN
CA1586OtherGROUP MEDICARE RAILROAD
OH0989499OtherGROUP MEDICAID
OH000000177535OtherUNISON PIN
OH311413469030OtherCARESOURCE PIN
BU0499444OtherMEDICARE PTAN
OH0197989OtherUHC PIN
OH0437021Medicaid
OH000000177535OtherUNISON PIN
OH0197989OtherUHC PIN
CA1586OtherGROUP MEDICARE RAILROAD