Provider Demographics
NPI:1356542856
Name:BHUTTA, FAISAL MANZOOR (MD)
Entity type:Individual
Prefix:
First Name:FAISAL
Middle Name:MANZOOR
Last Name:BHUTTA
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:P.O. BOX 742342
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2342
Mailing Address - Country:US
Mailing Address - Phone:770-410-4366
Mailing Address - Fax:770-410-4664
Practice Address - Street 1:2500 HOSPITAL BLVD
Practice Address - Street 2:SUITE 420
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-4907
Practice Address - Country:US
Practice Address - Phone:770-410-4366
Practice Address - Fax:770-410-4664
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA069377207RP1001X
TN44940207RC0200X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1514048Medicaid
NC5913282Medicaid
VA1356542856Medicaid
TN3041881Medicare PIN