Basic Information
| Provider Information | |||||||||
| NPI: | 1528004488 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUTLER | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 25608 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841250608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063204476 | ||||||||
| FaxNumber: | 2065687043 | ||||||||
| Practice Location | |||||||||
| Address1: | 3400 CALIFORNIA AVE SW STE 300 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981163307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063203399 | ||||||||
| FaxNumber: | 2063205506 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 11/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0505X | MD00043901 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8431488 | 05 | WA | MEDICAID |