Provider Demographics
NPI:1417121013
Name:BUTAWAN-ALI, DOMINIQUE M (MD)
Entity Type:Individual
Prefix:MS
First Name:DOMINIQUE
Middle Name:M
Last Name:BUTAWAN-ALI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:DOMINIQUE
Other - Middle Name:M
Other - Last Name:BUTAWAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6215 HUMPHREYS BLVD STE 100
Mailing Address - Street 2:WCC MPLLC DBA MID SOUTH OB-GYN PPLC
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120
Mailing Address - Country:US
Mailing Address - Phone:901-747-1200
Mailing Address - Fax:901-747-1220
Practice Address - Street 1:6215 HUMPHREYS BLVD., STE 100
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120
Practice Address - Country:US
Practice Address - Phone:901-747-1200
Practice Address - Fax:901-747-1220
Is Sole Proprietor?:No
Enumeration Date:2008-04-15
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC201200884207V00000X
ARE-8519207V00000X
TN54889207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
344035YJH3Medicare UPIN