=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184621534
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN OLIVE DUNCAN-BUTLER M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2005
-----------------------------------------------------
Last Update Date | 10/25/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3614 PROVIDENCE RD S STE 101
-----------------------------------------------------
City | WAXHAW
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28173-6309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-384-8460
-----------------------------------------------------
Fax | 704-384-8771
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 60447
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28260-0447
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-384-7840
-----------------------------------------------------
Fax | 704-384-7830
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 2001-00861
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------