Healthcare Provider Details

I. General information

NPI: 1073152807
Provider Name (Legal Business Name): DORIAN BUTLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2019
Last Update Date: 12/26/2019
Certification Date: 12/26/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 N BROADWAY
BALTIMORE MD
21205-1832
US

IV. Provider business mailing address

2209 CROSSETT RD
ROSEDALE MD
21237
US

V. Phone/Fax

Practice location:
  • Phone: 443-923-2600
  • Fax:
Mailing address:
  • Phone: 443-413-1956
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR145391
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: