Provider Demographics
NPI:1205888757
Name:BUTLER, TASSO S JR (OD)
Entity type:Individual
Prefix:DR
First Name:TASSO
Middle Name:S
Last Name:BUTLER
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:US RT 219
Mailing Address - Street 2:GREENBRIER VALLEY MALL
Mailing Address - City:LEWISBURG
Mailing Address - State:WV
Mailing Address - Zip Code:24901
Mailing Address - Country:US
Mailing Address - Phone:304-645-2799
Mailing Address - Fax:304-647-3962
Practice Address - Street 1:413 GREENBRIER VALLY MALL DR
Practice Address - Street 2:SUITE 2
Practice Address - City:LEWISBURG
Practice Address - State:WV
Practice Address - Zip Code:24901-1794
Practice Address - Country:US
Practice Address - Phone:304-645-2799
Practice Address - Fax:304-647-3962
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0601000803152W00000X
WV658OD152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001717454OtherBC BS MT STATE
WV410002504OtherRR MEDICARE
WV0150878000Medicaid
VA410038164OtherRAILROAD MEDICARE
VA009206698Medicaid
VA208525OtherBLUE CROSS/BLUE SHIELD
VAT32386Medicare UPIN
WV410002504OtherRR MEDICARE
VA009206698Medicaid
VA208525OtherBLUE CROSS/BLUE SHIELD
WVBU0568211Medicare PIN