Healthcare Provider Details

I. General information

NPI: 1679519391
Provider Name (Legal Business Name): KEITH CLAUDE BUTLER MD MBA FACEP CPE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 10/29/2021
Certification Date: 10/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 S VAL VISA SUITE A3-624
GILBERT AZ
85296-1335
US

IV. Provider business mailing address

70 S VAL VISA SUITE A3-624
GILBERT AZ
85296-1335
US

V. Phone/Fax

Practice location:
  • Phone: 877-336-6898
  • Fax:
Mailing address:
  • Phone: 877-336-6898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number26876
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207PE0005X
TaxonomyUndersea and Hyperbaric Medicine (Emergency Medicine) Physician
License Number26876
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: