Provider Demographics
NPI:1245096940
Name:BUTLER, TAE LEON
Entity type:Individual
Prefix:
First Name:TAE
Middle Name:LEON
Last Name:BUTLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:885 TIVERTON DRIVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-0001
Mailing Address - Country:US
Mailing Address - Phone:310-825-6373
Mailing Address - Fax:
Practice Address - Street 1:757 WESTWOOD PLZ
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-0001
Practice Address - Country:US
Practice Address - Phone:310-267-9124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-21
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16386208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208000000XAllopathic & Osteopathic PhysiciansPediatrics