Provider Demographics
NPI:1942206636
Name:BUTLER, THOMAS WALKER (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:WALKER
Last Name:BUTLER
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 1:6501 PEAKE RD
Mailing Address - Street 2:STE 900
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-8051
Mailing Address - Country:US
Mailing Address - Phone:478-757-8868
Mailing Address - Fax:478-757-3285
Practice Address - Street 1:6501 PEAKE RD
Practice Address - Street 2:STE 900
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-8051
Practice Address - Country:US
Practice Address - Phone:478-757-8868
Practice Address - Fax:478-757-3285
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA199152085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0004345960Medicaid
GA0004345960Medicaid
30BDLKCMedicare ID - Type Unspecified