Healthcare Provider Details

I. General information

NPI: 1205093473
Provider Name (Legal Business Name): ASIF BHUTTO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2008
Last Update Date: 03/15/2021
Certification Date: 03/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3466 BRIDGELAND DR STE 105
BRIDGETON MO
63044-2606
US

IV. Provider business mailing address

PO BOX 8356
SAINT LOUIS MO
63132-0356
US

V. Phone/Fax

Practice location:
  • Phone: 314-209-5100
  • Fax:
Mailing address:
  • Phone: 314-977-8462
  • Fax: 314-771-8575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number2004-012733
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2008007521
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number2008007521
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: