Provider Demographics
NPI:1891734372
Name:BUTELA, SHAWN T (MD)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:T
Last Name:BUTELA
Suffix:
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 1:110 KINGSLEY LN
Mailing Address - Street 2:SUITE 305
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23505-4614
Mailing Address - Country:US
Mailing Address - Phone:757-889-5942
Mailing Address - Fax:757-889-5422
Practice Address - Street 1:110 KINGSLEY LN
Practice Address - Street 2:SUITE 305
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23505-4614
Practice Address - Country:US
Practice Address - Phone:757-889-5942
Practice Address - Fax:757-889-5422
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA711432085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A711430Medicaid
CA00A711430OtherBLUE SHIELD
CA00A711430OtherBLUE SHIELD
CAWA71143AMedicare PIN
H31534Medicare UPIN
CAWA71143BMedicare PIN
CAWA71143DMedicare PIN
CAWA71143CMedicare PIN