Provider Demographics
NPI:1831342799
Name:BUTLER, EDWIN EUGENE (MD)
Entity type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:EUGENE
Last Name:BUTLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2265 E SUNNYSIDE RD
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7598
Mailing Address - Country:US
Mailing Address - Phone:208-542-5000
Mailing Address - Fax:208-542-5151
Practice Address - Street 1:1320 BISHOP RANDALL DR
Practice Address - Street 2:DEPARTMENT OF RADIOLOGY
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-3939
Practice Address - Country:US
Practice Address - Phone:307-335-6251
Practice Address - Fax:307-335-6467
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-23
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-148192085R0202X
MT780542085R0202X
WY9415A2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY136028100Medicaid
WY136028100Medicaid