Provider Demographics
NPI:1780668699
Name:BUTLER, JOE JR (MD)
Entity Type:Individual
Prefix:
First Name:JOE
Middle Name:
Last Name:BUTLER
Suffix:JR
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 1:2525 HARBOR BLVD
Mailing Address - Street 2:STE 309
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-5344
Mailing Address - Country:US
Mailing Address - Phone:941-629-7597
Mailing Address - Fax:941-629-5070
Practice Address - Street 1:2525 HARBOR BLVD
Practice Address - Street 2:STE 309
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-5344
Practice Address - Country:US
Practice Address - Phone:941-629-7597
Practice Address - Fax:941-629-5070
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME39536208600000X, 208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgery
Not Answered208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
D61542Medicare UPIN
99863Medicare ID - Type UnspecifiedGROUP
8117ZMedicare ID - Type Unspecified