Healthcare Provider Details

I. General information

NPI: 1164581625
Provider Name (Legal Business Name): PROMIL BHUTANI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PROMIL ALAWADHI MD

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 11/26/2025
Certification Date: 11/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 ELM ST N
FARGO ND
58102-2417
US

IV. Provider business mailing address

2101 ELM ST N
FARGO ND
58102-2417
US

V. Phone/Fax

Practice location:
  • Phone: 701-335-4380
  • Fax:
Mailing address:
  • Phone: 701-335-4380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2006-0509
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number52748
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: