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General NPI Number Information
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NPI Number | 1770873879
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Entity Type | Individual
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Provider Name | JONATHAN TY BUTLER M.D., PH.D.
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Gender | Male
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Dates
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Enumeration Date | 04/11/2011
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Last Update Date | 08/08/2016
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Provider Practice Location Address
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Address Line | 12200 WARWICK BLVD STE 110 RIVERSIDE NEUROLOGY SPECIALISTS
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City | NEWPORT NEWS
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State | VA
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Zip | 23601-2344
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Country | US
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Telephone | 757-534-5100
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Fax | 757-534-5395
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Provider Business Mailing Address
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Address Line | 856 J CLYDE MORRIS BLVD STE A RIVERSIDE MEDICAL GROUP
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City | NEWPORT NEWS
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State | VA
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Zip | 23601-1318
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Country | US
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Telephone | 757-594-4006
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number | 0101260074
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License Number State | VA
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