Healthcare Provider Details

I. General information

NPI: 1396753018
Provider Name (Legal Business Name): SHADAB MUHAMMAD BHUTTO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 12/06/2024
Certification Date: 12/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 S 3RD ST
BELLEVILLE IL
62220-1952
US

IV. Provider business mailing address

180 S 3RD ST
BELLEVILLE IL
62220-1952
US

V. Phone/Fax

Practice location:
  • Phone: 618-222-4701
  • Fax: 618-222-4754
Mailing address:
  • Phone: 618-222-4701
  • Fax: 618-222-4754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2008030162
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036151344
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: