Provider Demographics
NPI:1093561995
Name:BUTLER, JERMAINE LAMONT
Entity type:Individual
Prefix:
First Name:JERMAINE
Middle Name:LAMONT
Last Name:BUTLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:246 E GREENWICH AVE
Mailing Address - Street 2:
Mailing Address - City:ROOSEVELT
Mailing Address - State:NY
Mailing Address - Zip Code:11575-1205
Mailing Address - Country:US
Mailing Address - Phone:718-413-6822
Mailing Address - Fax:
Practice Address - Street 1:246 E GREENWICH AVE
Practice Address - Street 2:
Practice Address - City:ROOSEVELT
Practice Address - State:NY
Practice Address - Zip Code:11575-1205
Practice Address - Country:US
Practice Address - Phone:718-413-6822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-30
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty