Provider Demographics
NPI:1730714965
Name:BUTLER, JODI
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:
Last Name:BUTLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 W GRANADA BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-5941
Mailing Address - Country:US
Mailing Address - Phone:386-675-6599
Mailing Address - Fax:386-256-2007
Practice Address - Street 1:900 W GRANADA BLVD STE 1
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5941
Practice Address - Country:US
Practice Address - Phone:386-675-6599
Practice Address - Fax:386-256-2007
Is Sole Proprietor?:No
Enumeration Date:2020-03-09
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO6859156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician