Provider Demographics
NPI:1689918815
Name:BUTT, MARIUM (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIUM
Middle Name:
Last Name:BUTT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3801 S NATIONAL AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-5210
Mailing Address - Country:US
Mailing Address - Phone:417-269-7728
Mailing Address - Fax:417-269-7729
Practice Address - Street 1:3801 S NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5210
Practice Address - Country:US
Practice Address - Phone:417-269-7728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-10
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS4739207R00000X
MO2023030155207R00000X
IL036133148208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILFB4008618OtherDEA