Healthcare Provider Details

I. General information

NPI: 1891771374
Provider Name (Legal Business Name): MITCHELL P BUTIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 06/26/2022
Certification Date: 06/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 FORDHAM PLZ RM 908
BRONX NY
10458-5890
US

IV. Provider business mailing address

PO BOX 565 CATHEDRAL STATION
NEW YORK NY
10025
US

V. Phone/Fax

Practice location:
  • Phone: 718-365-4044
  • Fax:
Mailing address:
  • Phone: 914-484-6513
  • Fax: 888-511-7297

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number034914
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number156361
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: