Provider Demographics
NPI:1710174800
Name:DAVID J BUTUK MD PA
Entity Type:Organization
Organization Name:DAVID J BUTUK MD PA
Other - Org Name:MERIDIAN FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:BUTUK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-888-1199
Mailing Address - Street 1:PO BOX 44440
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83711-0440
Mailing Address - Country:US
Mailing Address - Phone:208-888-1199
Mailing Address - Fax:208-888-0807
Practice Address - Street 1:1525 E LEIGHFIELD DR
Practice Address - Street 2:SUITE 150
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-5371
Practice Address - Country:US
Practice Address - Phone:208-888-1199
Practice Address - Fax:208-888-0807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-02
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806698100Medicaid
1376021Medicare PIN