Provider Demographics
NPI:1104925205
Name:BUTERA, MICHAEL LAWRENCE (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LAWRENCE
Last Name:BUTERA
Suffix:
Gender:M
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:PO BOX 1009
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91979-1009
Mailing Address - Country:US
Mailing Address - Phone:619-508-0908
Mailing Address - Fax:619-693-3242
Practice Address - Street 1:6699 ALVARADO RD STE 2309
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-5241
Practice Address - Country:US
Practice Address - Phone:619-286-8803
Practice Address - Fax:619-286-2344
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG70238207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G702380Medicaid
WG70238COtherMEDICARE PTAN
CA00G702380Medicaid
G70238Medicare PIN