Healthcare Provider Details

I. General information

NPI: 1447386099
Provider Name (Legal Business Name): WENDELL DECAMP BUTLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 10/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

653 N TOWN CENTER DR SUITE 502
LAS VEGAS NV
89144-0514
US

IV. Provider business mailing address

653 N TOWN CENTER DR SUITE 502
LAS VEGAS NV
89144-0514
US

V. Phone/Fax

Practice location:
  • Phone: 702-242-4102
  • Fax: 702-242-0177
Mailing address:
  • Phone: 702-242-4102
  • Fax: 702-242-0177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5642
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: