Provider Demographics
NPI:1710243126
Name:BUTANIS, MARK (IDMT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:BUTANIS
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3913 N I 10 SERVICE RD W APT 239
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70002-6828
Mailing Address - Country:US
Mailing Address - Phone:717-659-3239
Mailing Address - Fax:
Practice Address - Street 1:3913 N I 10 SERVICE RD W APT 239
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70002-6828
Practice Address - Country:US
Practice Address - Phone:717-659-3239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-10
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians