Provider Demographics
NPI:1902992894
Name:BUTT, GLENN A (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:A
Last Name:BUTT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1514 JEFFERSON HWY
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70121-2429
Mailing Address - Country:US
Mailing Address - Phone:504-842-4000
Mailing Address - Fax:
Practice Address - Street 1:64629 HIGHWAY 41
Practice Address - Street 2:
Practice Address - City:PEARL RIVER
Practice Address - State:LA
Practice Address - Zip Code:70452-3611
Practice Address - Country:US
Practice Address - Phone:985-863-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA13870R207R00000X
MS17113207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1439959Medicaid
MS00125336Medicaid
E10173Medicare UPIN
LA1439959Medicaid
MS00125336Medicaid
4E079Medicare PIN