Provider Demographics
NPI:1538247135
Name:BUTLER, SAMUEL W (OD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:W
Last Name:BUTLER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 707
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:IA
Mailing Address - Zip Code:51301-0707
Mailing Address - Country:US
Mailing Address - Phone:712-262-1589
Mailing Address - Fax:712-262-3689
Practice Address - Street 1:3 E 18TH ST
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:IA
Practice Address - Zip Code:51301-3441
Practice Address - Country:US
Practice Address - Phone:712-262-1589
Practice Address - Fax:712-262-3689
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02135152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0198416Medicaid
IA05577OtherBLUE CROSS BLUE SHIELD
IA05577OtherBLUE CROSS BLUE SHIELD
IAU77794Medicare UPIN