Provider Demographics
NPI:1366406654
Name:GILL BUTLER, TERI S (OPTOMITRIST)
Entity type:Individual
Prefix:DR
First Name:TERI
Middle Name:S
Last Name:GILL BUTLER
Suffix:
Gender:F
Credentials:OPTOMITRIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3713 MARCHBANKS CIR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-8755
Mailing Address - Country:US
Mailing Address - Phone:870-236-9371
Mailing Address - Fax:870-236-8984
Practice Address - Street 1:2711 W KINGSHIGHWAY
Practice Address - Street 2:SUITE 4
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-2604
Practice Address - Country:US
Practice Address - Phone:870-236-9371
Practice Address - Fax:870-236-8984
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-13
Last Update Date:2013-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2531152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR148781722Medicaid
AR49835OtherBLUE CROSS/BLUE SHIELD
ARU93161Medicare UPIN
AR148781722Medicaid