Provider Demographics
NPI:1245229145
Name:TABBUT, BYRON R (MD)
Entity Type:Individual
Prefix:DR
First Name:BYRON
Middle Name:R
Last Name:TABBUT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3192 WILLOW CREEK RD
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-6610
Mailing Address - Country:US
Mailing Address - Phone:928-778-1234
Mailing Address - Fax:928-778-3999
Practice Address - Street 1:2015 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-3152
Practice Address - Country:US
Practice Address - Phone:630-668-8250
Practice Address - Fax:630-668-8916
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-072686207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL180012231OtherRR MEDICARE
IL036072686Medicaid
IL036072686Medicaid
IL0534150002Medicare NSC
IL180012231OtherRR MEDICARE
IL0534150004Medicare NSC
ILC39528Medicare UPIN
ILP01057Medicare PIN