Provider Demographics
NPI:1356325476
Name:BUTLER, FRED A (OD)
Entity type:Individual
Prefix:MR
First Name:FRED
Middle Name:A
Last Name:BUTLER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3630 11TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-4276
Mailing Address - Country:US
Mailing Address - Phone:507-288-2457
Mailing Address - Fax:507-288-1299
Practice Address - Street 1:3630 11TH AVE NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-4276
Practice Address - Country:US
Practice Address - Phone:507-288-2457
Practice Address - Fax:507-288-1299
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1676152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN4C933BUOtherBLUE CROSS SHIELD
MN094523400Medicaid
2201135OtherMEDICA CHOICE SELECT
HP44091OtherHEALTH PARTNERS
01017732OtherPREFERRED ONE
01017732OtherPREFERRED ONE
2201135OtherMEDICA CHOICE SELECT
T39414Medicare UPIN