Provider Demographics
NPI:1962657577
Name:BUTALA, MADHURA NITIN (MD)
Entity Type:Individual
Prefix:DR
First Name:MADHURA
Middle Name:NITIN
Last Name:BUTALA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MADHURA
Other - Middle Name:R
Other - Last Name:PATWARDHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:13241 BARTRAM PARK BLVD
Mailing Address - Street 2:#209
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-5212
Mailing Address - Country:US
Mailing Address - Phone:904-242-4220
Mailing Address - Fax:904-242-4221
Practice Address - Street 1:13770 BEACH BLVD
Practice Address - Street 2:#6
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-7205
Practice Address - Country:US
Practice Address - Phone:904-242-4220
Practice Address - Fax:904-242-4221
Is Sole Proprietor?:No
Enumeration Date:2008-11-24
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME109013208000000X
IL125050936208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013603100Medicaid