Provider Demographics
NPI:1780646539
Name:BUTTER, DESIREE BETH (MD)
Entity Type:Individual
Prefix:DR
First Name:DESIREE
Middle Name:BETH
Last Name:BUTTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 BRADFORD RD
Mailing Address - Street 2:STONEWOOD COMMONS I SUITE 220
Mailing Address - City:WEXFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15090-6909
Mailing Address - Country:US
Mailing Address - Phone:724-940-5555
Mailing Address - Fax:724-940-5556
Practice Address - Street 1:101 BRADFORD RD
Practice Address - Street 2:STONEWOOD COMMONS I SUITE 220
Practice Address - City:WEXFORD
Practice Address - State:PA
Practice Address - Zip Code:15090-6909
Practice Address - Country:US
Practice Address - Phone:724-940-5555
Practice Address - Fax:724-940-5556
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-06
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-060804-L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA078854Medicare ID - Type Unspecified
PAG43197Medicare UPIN