Healthcare Provider Details

I. General information

NPI: 1982851390
Provider Name (Legal Business Name): BRENT A. BUTCHER, MD, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2008
Last Update Date: 10/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 W LEGION RD
BRAWLEY CA
92227-7780
US

IV. Provider business mailing address

3639 MIDWAY DR SUITE B, #412
SAN DIEGO CA
92110-5254
US

V. Phone/Fax

Practice location:
  • Phone: 760-351-4848
  • Fax: 760-351-4849
Mailing address:
  • Phone: 619-258-6200
  • Fax: 619-258-0028

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0005X
TaxonomyUndersea and Hyperbaric Medicine (Emergency Medicine) Physician
License NumberA67738
License Number StateCA

VIII. Authorized Official

Name: BRENT A. BUTCHER
Title or Position: OWNER/PRESIDENT
Credential: MD
Phone: 619-990-9317