Provider Demographics
NPI:1720184948
Name:BUTALA, AMITA ATUL (MD)
Entity Type:Individual
Prefix:DR
First Name:AMITA
Middle Name:ATUL
Last Name:BUTALA
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 1:2209 GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-5999
Mailing Address - Country:US
Mailing Address - Phone:315-801-8534
Mailing Address - Fax:315-801-8391
Practice Address - Street 1:1617 N JAMES ST STE 900
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440-2846
Practice Address - Country:US
Practice Address - Phone:315-336-8260
Practice Address - Fax:315-314-8536
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY187464207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01382732Medicaid
NYF22256Medicare UPIN
NY01382732Medicaid