Provider Demographics
NPI:1376164541
Name:BUTT, IFTIKHAR (PA)
Entity Type:Individual
Prefix:
First Name:IFTIKHAR
Middle Name:
Last Name:BUTT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 STABLEGATE DR
Mailing Address - Street 2:
Mailing Address - City:CLIFTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12065-6796
Mailing Address - Country:US
Mailing Address - Phone:518-210-5571
Mailing Address - Fax:
Practice Address - Street 1:17 STABLEGATE DR
Practice Address - Street 2:
Practice Address - City:CLIFTON PARK
Practice Address - State:NY
Practice Address - Zip Code:12065-6796
Practice Address - Country:US
Practice Address - Phone:518-210-5571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-29
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0350191207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology