Healthcare Provider Details

I. General information

NPI: 1871562165
Provider Name (Legal Business Name): JERRY BUTTO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 10/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 FORT ST SUITE 250
TRENTON MI
48183-4632
US

IV. Provider business mailing address

5400 FORT ST SUITE 250
TRENTON MI
48183-4632
US

V. Phone/Fax

Practice location:
  • Phone: 734-671-8500
  • Fax: 734-671-8503
Mailing address:
  • Phone: 734-671-8500
  • Fax: 734-671-8503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number5101012712
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: