Healthcare Provider Details

I. General information

NPI: 1699029694
Provider Name (Legal Business Name): FLOYD DENARD BUTLER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2012
Last Update Date: 10/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10245 HECTORVILLE RD
MOUNDS OK
74047-4249
US

IV. Provider business mailing address

10245 HECTORVILLE RD
MOUNDS OK
74047-4249
US

V. Phone/Fax

Practice location:
  • Phone: 660-202-9779
  • Fax:
Mailing address:
  • Phone: 660-202-9779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberJ083438512
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: