Provider Demographics
NPI:1619366499
Name:BUTALA, ANISH ATUL (MD)
Entity Type:Individual
Prefix:
First Name:ANISH
Middle Name:ATUL
Last Name:BUTALA
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 1:3400 CIVIC CENTER BOULEVARD
Mailing Address - Street 2:TRC-2 WEST
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104
Mailing Address - Country:US
Mailing Address - Phone:267-438-7203
Mailing Address - Fax:
Practice Address - Street 1:3400 CIVIC CENTER BOULEVARD
Practice Address - Street 2:TRC-2 WEST
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104
Practice Address - Country:US
Practice Address - Phone:267-438-7203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-15
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT210439207R00000X
390200000X
PAMD4724502085R0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program