Provider Demographics
NPI:1982851390
Name:BRENT A. BUTCHER, MD, INC.
Entity Type:Organization
Organization Name:BRENT A. BUTCHER, MD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:A
Authorized Official - Last Name:BUTCHER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-990-9317
Mailing Address - Street 1:3639 MIDWAY DR
Mailing Address - Street 2:SUITE B, #412
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-5254
Mailing Address - Country:US
Mailing Address - Phone:619-258-6200
Mailing Address - Fax:619-258-0028
Practice Address - Street 1:207 W LEGION RD
Practice Address - Street 2:
Practice Address - City:BRAWLEY
Practice Address - State:CA
Practice Address - Zip Code:92227-7780
Practice Address - Country:US
Practice Address - Phone:760-351-4848
Practice Address - Fax:760-351-4849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-27
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA67738207PE0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric MedicineGroup - Single Specialty