Healthcare Provider Details

I. General information

NPI: 1093762502
Provider Name (Legal Business Name): AWAIS IJAZ BUTT D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 12/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2971 FAIRBURN RD
DOUGLASVILLE GA
30135-2915
US

IV. Provider business mailing address

2971 FAIRBURN RD
DOUGLASVILLE GA
30135-2915
US

V. Phone/Fax

Practice location:
  • Phone: 770-783-1799
  • Fax: 770-573-0559
Mailing address:
  • Phone: 770-783-1799
  • Fax: 770-573-0559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIR007770
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: