Healthcare Provider Details

I. General information

NPI: 1235074980
Provider Name (Legal Business Name): DEMEETRIO BUTLER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2026
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 FREEMAN CT
COMMACK NY
11725-3911
US

IV. Provider business mailing address

1 FREEMAN CT
COMMACK NY
11725-3911
US

V. Phone/Fax

Practice location:
  • Phone: 347-909-6036
  • Fax:
Mailing address:
  • Phone: 347-909-6036
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License NumberNYAZ0500098R
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: