Healthcare Provider Details

I. General information

NPI: 1083615421
Provider Name (Legal Business Name): DAVID BUTTROSS III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 07/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 DR MICHAEL DEBAKEY DR SUITE 220
LAKE CHARLES LA
70601-5887
US

IV. Provider business mailing address

333 DR MICHAEL DEBAKEY DR SUITE 220
LAKE CHARLES LA
70601-5887
US

V. Phone/Fax

Practice location:
  • Phone: 337-478-9331
  • Fax: 337-478-9828
Mailing address:
  • Phone: 337-478-9331
  • Fax: 337-478-9828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number021316
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: