Healthcare Provider Details

I. General information

NPI: 1114730199
Provider Name (Legal Business Name): ROBERT BUTLER MLT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2025
Last Update Date: 01/31/2025
Certification Date: 01/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9114 HOGARTEN PARK
CONVERSE TX
78109-2804
US

IV. Provider business mailing address

9114 HOGARTEN PARK
CONVERSE TX
78109-2804
US

V. Phone/Fax

Practice location:
  • Phone: 210-792-1839
  • Fax:
Mailing address:
  • Phone: 210-792-1839
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RM2200X
TaxonomyMedical Laboratory Technician
License Number25438422
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: