Provider Demographics
NPI:1851679062
Name:BUTLER, JAMES RUSSELL (MD, PHD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:RUSSELL
Last Name:BUTLER
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:545 BARNHILL DR
Practice Address - Street 2:EMERSON HALL 202
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5112
Practice Address - Country:US
Practice Address - Phone:317-274-5771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-22
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11016293A208600000X
IN01077045A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300055010Medicaid
IN233690135OtherMEDICARE PTAN