Healthcare Provider Details

I. General information

NPI: 1962657577
Provider Name (Legal Business Name): MADHURA NITIN BUTALA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MADHURA R PATWARDHAN MD

II. Dates (important events)

Enumeration Date: 11/24/2008
Last Update Date: 01/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13770 BEACH BLVD #6
JACKSONVILLE FL
32224-7205
US

IV. Provider business mailing address

13241 BARTRAM PARK BLVD #209
JACKSONVILLE FL
32258-5212
US

V. Phone/Fax

Practice location:
  • Phone: 904-242-4220
  • Fax: 904-242-4221
Mailing address:
  • Phone: 904-242-4220
  • Fax: 904-242-4221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME109013
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125050936
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: