Provider Demographics
NPI:1679823926
Name:BUTLER, JAMES JACKSON (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:JACKSON
Last Name:BUTLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JACK
Other - Middle Name:J
Other - Last Name:BUTLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:11234 ANDERSON ST
Mailing Address - Street 2:GME OFFICE WESTERLY SUITE C
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-2804
Mailing Address - Country:US
Mailing Address - Phone:909-558-4475
Mailing Address - Fax:909-558-4143
Practice Address - Street 1:11234 ANDERSON ST
Practice Address - Street 2:GRADUATE MEDICAL EDUCATION OFFICE CSP21005
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-2804
Practice Address - Country:US
Practice Address - Phone:909-558-4475
Practice Address - Fax:909-558-4143
Is Sole Proprietor?:No
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG 88943207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology