Provider Demographics
NPI:1669427290
Name:BUTORAC, RICHARD BRIAN (IDC)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:BRIAN
Last Name:BUTORAC
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5113 BAYRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76179-4255
Mailing Address - Country:US
Mailing Address - Phone:904-588-2906
Mailing Address - Fax:
Practice Address - Street 1:1711 DOOLITTLE AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76179
Practice Address - Country:US
Practice Address - Phone:904-588-2906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman