Provider Demographics
NPI:1942560172
Name:BUTT, AWAIS (MD)
Entity Type:Individual
Prefix:
First Name:AWAIS
Middle Name:
Last Name:BUTT
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 1:3022 S PARK AVE
Mailing Address - Street 2:
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948-3721
Mailing Address - Country:US
Mailing Address - Phone:618-988-9777
Mailing Address - Fax:618-988-9097
Practice Address - Street 1:3022 S PARK AVE
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-3721
Practice Address - Country:US
Practice Address - Phone:618-988-9777
Practice Address - Fax:618-988-9097
Is Sole Proprietor?:No
Enumeration Date:2012-05-22
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-131112207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1942560172OtherNPI
IL036-131112OtherLICENSE