Provider Demographics
NPI:1750312963
Name:BUTLER, GLORIA J (MD)
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:J
Last Name:BUTLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 N FRONTAGE RD
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-5102
Mailing Address - Country:US
Mailing Address - Phone:601-634-8790
Mailing Address - Fax:
Practice Address - Street 1:2200 HIGHWAY 61 N
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39183-8246
Practice Address - Country:US
Practice Address - Phone:601-883-3340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10669207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1994014Medicaid
MS5968106OtherAETNA
MS4251157OtherBCBS
MS0010931Medicaid
MS512I080263Medicare PIN
MS5968106OtherAETNA
MS080003292Medicare PIN
MS080003289Medicare PIN
MS4251157OtherBCBS