Provider Demographics
NPI:1164581625
Name:BHUTANI, PROMIL (MD)
Entity Type:Individual
Prefix:
First Name:PROMIL
Middle Name:
Last Name:BHUTANI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PROMIL
Other - Middle Name:
Other - Last Name:ALAWADHI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3221 32ND AVE S
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-6071
Mailing Address - Country:US
Mailing Address - Phone:701-335-4380
Mailing Address - Fax:
Practice Address - Street 1:3221 32ND AVE S
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-6071
Practice Address - Country:US
Practice Address - Phone:701-335-4380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2006-0509207Q00000X
MN52748207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM03073335Medicaid
NMMD2006-0509OtherLICENSE
NMNM001P81OtherBCBS
NMP00405998OtherRAILROAD MEDICARE
MN1164581625Medicaid
NM346708601Medicare PIN
NMP00405998OtherRAILROAD MEDICARE
NMMD2006-0509OtherLICENSE