Provider Demographics
NPI:1619473733
Name:BUTUZOV, NICOLE ANNA (DO)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANNA
Last Name:BUTUZOV
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1345 RXR PLZ
Mailing Address - Street 2:FL 13
Mailing Address - City:UNIONDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11556-1301
Mailing Address - Country:US
Mailing Address - Phone:718-206-6942
Mailing Address - Fax:
Practice Address - Street 1:41 MALL RD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01805-2618
Practice Address - Country:US
Practice Address - Phone:781-744-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-05
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY311861207Q00000X
390200000X
MA295367207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program