Provider Demographics
NPI:1972045110
Name:BUTCH, ANTHONY (PHD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:BUTCH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2122 GRANVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-6106
Mailing Address - Country:US
Mailing Address - Phone:310-312-1509
Mailing Address - Fax:310-206-9077
Practice Address - Street 1:2122 GRANVILLE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-6106
Practice Address - Country:US
Practice Address - Phone:310-312-1509
Practice Address - Fax:310-206-9077
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-04
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADRH 091247ZC0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physician