Healthcare Provider Details

I. General information

NPI: 1740483882
Provider Name (Legal Business Name): NITIN SANTOSH BUTALA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2007
Last Update Date: 01/07/2025
Certification Date: 01/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

841 PRUDENTIAL DR FL 10
JACKSONVILLE FL
32207-8329
US

IV. Provider business mailing address

PO BOX 41113
JACKSONVILLE FL
32203-1113
US

V. Phone/Fax

Practice location:
  • Phone: 904-394-5404
  • Fax: 904-391-5545
Mailing address:
  • Phone: 904-376-3707
  • Fax: 904-636-5786

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License NumberME108771
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberME108771
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: