Provider Demographics
NPI:1992773196
Name:BUTLER, BRADLEY S (MD)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:S
Last Name:BUTLER
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 491028
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30049
Mailing Address - Country:US
Mailing Address - Phone:404-605-3247
Mailing Address - Fax:404-609-6645
Practice Address - Street 1:1968 PEACHTREE RD NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309
Practice Address - Country:US
Practice Address - Phone:404-605-3247
Practice Address - Fax:404-609-6645
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA054980207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA524899677CMedicaid
H68740Medicare UPIN
GA524899677CMedicaid
GAP00161730Medicare PIN
GA22BDDPJMedicare PIN