Provider Demographics
NPI:1801942214
Name:BUTT, FAHEEM M (MD)
Entity type:Individual
Prefix:MR
First Name:FAHEEM
Middle Name:M
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 1:82 CROYDEN CT
Mailing Address - Street 2:
Mailing Address - City:ALBERTSON
Mailing Address - State:NY
Mailing Address - Zip Code:11507-2228
Mailing Address - Country:US
Mailing Address - Phone:718-638-8185
Mailing Address - Fax:
Practice Address - Street 1:481 SAINT MARKS AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11238-3708
Practice Address - Country:US
Practice Address - Phone:718-638-8185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY186151174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01444068Medicaid
NY01444068Medicaid
NY02H401Medicare ID - Type Unspecified