Provider Demographics
NPI:1316925449
Name:BUTLER, JACK D (DO)
Entity type:Individual
Prefix:MR
First Name:JACK
Middle Name:D
Last Name:BUTLER
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:5300 N INDEPENDENCE AVE
Mailing Address - Street 2:STE 280
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-5556
Mailing Address - Country:US
Mailing Address - Phone:405-713-7403
Mailing Address - Fax:405-713-2794
Practice Address - Street 1:3300 NW EXPRESSWAY
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-4418
Practice Address - Country:US
Practice Address - Phone:405-713-7403
Practice Address - Fax:405-713-2794
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2017-07-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ1786207R00000X
OK2084207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ240010Medicaid
AZE44462Medicare UPIN