Provider Demographics
NPI:1962491035
Name:BUTLER, JACK M (MD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:M
Last Name:BUTLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2 GREENWAY PLZ
Mailing Address - Street 2:SUITE 900
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77046-0297
Mailing Address - Country:US
Mailing Address - Phone:713-798-1835
Mailing Address - Fax:713-798-1144
Practice Address - Street 1:1504 TAUB LOOP
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-1608
Practice Address - Country:US
Practice Address - Phone:713-873-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2009-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL2828207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX155777902Medicaid
TX155777905Medicaid
NM10651721Medicaid
TX8U6943OtherBCBS
TXL2828OtherSTATE LICENSE
TXP00334341OtherRAILROAD
NM10651721Medicaid
TX155777902Medicaid
TX8G3252Medicare PIN
TX8U6943OtherBCBS