Healthcare Provider Details

I. General information

NPI: 1669861548
Provider Name (Legal Business Name): DAVIETTA BUTTY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2015
Last Update Date: 07/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4855 S MOORLAND RD
NEW BERLIN WI
53151
US

IV. Provider business mailing address

1630 W 33RD PL
CHICAGO IL
60608-6202
US

V. Phone/Fax

Practice location:
  • Phone: 262-432-7599
  • Fax: 262-432-7694
Mailing address:
  • Phone: 248-761-6924
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number66509-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: