Provider Demographics
NPI:1023037082
Name:BUTROS, REZKALLA (MD)
Entity Type:Individual
Prefix:MR
First Name:REZKALLA
Middle Name:
Last Name:BUTROS
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 1:148 SKYVIEW DRIVE
Mailing Address - Street 2:
Mailing Address - City:MT. STERLING
Mailing Address - State:KY
Mailing Address - Zip Code:40351-1300
Mailing Address - Country:US
Mailing Address - Phone:859-499-0717
Mailing Address - Fax:859-499-0926
Practice Address - Street 1:148 SKYVIEW DRIVE
Practice Address - Street 2:
Practice Address - City:MT. STERLING
Practice Address - State:KY
Practice Address - Zip Code:40351-1300
Practice Address - Country:US
Practice Address - Phone:859-499-0717
Practice Address - Fax:859-499-0926
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY34280207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65938888Medicaid
KY31-001050Medicaid
KY64015977Medicaid
KY64015977Medicaid
KY65938888Medicaid
0772901Medicare PIN