Provider Demographics
NPI:1740483882
Name:BUTALA, NITIN SANTOSH (MD)
Entity type:Individual
Prefix:DR
First Name:NITIN
Middle Name:SANTOSH
Last Name:BUTALA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 41113
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32203-1113
Mailing Address - Country:US
Mailing Address - Phone:904-376-3707
Mailing Address - Fax:904-636-5786
Practice Address - Street 1:841 PRUDENTIAL DR FL 10
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8329
Practice Address - Country:US
Practice Address - Phone:904-394-5404
Practice Address - Fax:904-391-5545
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1087712084N0600X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01050785OtherRR MEDICARE
FL0039592-00Medicaid
FLP01050785OtherRR MEDICARE