Healthcare Provider Details

I. General information

NPI: 1194819474
Provider Name (Legal Business Name): MUJTABA I BUTT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 09/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 KINGSLEY AVE SUITE 1101
ORANGE PARK FL
32073-4504
US

IV. Provider business mailing address

4800 BELFORT RD
JACKSONVILLE FL
32256-6004
US

V. Phone/Fax

Practice location:
  • Phone: 904-264-9797
  • Fax: 904-264-4644
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberME116837
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: