Provider Demographics
NPI:1427437664
Name:BUTLER, PORSHA (MD)
Entity type:Individual
Prefix:
First Name:PORSHA
Middle Name:
Last Name:BUTLER
Suffix:
Gender:F
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 1137
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32902-1137
Mailing Address - Country:US
Mailing Address - Phone:321-952-9696
Mailing Address - Fax:321-952-7937
Practice Address - Street 1:220 BARTON BLVD UNIT C-14
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-2742
Practice Address - Country:US
Practice Address - Phone:321-639-5177
Practice Address - Fax:321-639-4927
Is Sole Proprietor?:No
Enumeration Date:2015-05-20
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME140891208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102963000Medicaid