Healthcare Provider Details

I. General information

NPI: 1003831629
Provider Name (Legal Business Name): BRIAN K BUTCHER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 12/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11835 FISHING POINT DR STE 207
NEWPORT NEWS VA
23606
US

IV. Provider business mailing address

895 CITY CENTER BLVD 200
NEWPORT NEWS VA
23606-3080
US

V. Phone/Fax

Practice location:
  • Phone: 757-873-3334
  • Fax: 757-873-1128
Mailing address:
  • Phone: 757-599-4090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number0101225820
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: