Healthcare Provider Details

I. General information

NPI: 1417121013
Provider Name (Legal Business Name): DOMINIQUE M BUTAWAN-ALI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DOMINIQUE M BUTAWAN M.D.

II. Dates (important events)

Enumeration Date: 04/15/2008
Last Update Date: 10/16/2025
Certification Date: 10/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6215 HUMPHREYS BLVD STE 100 MID SOUTH OB-GYN PLLC
MEMPHIS TN
38120
US

IV. Provider business mailing address

6215 HUMPHREYS BLVD STE 100
MEMPHIS TN
38120-2382
US

V. Phone/Fax

Practice location:
  • Phone: 901-747-1200
  • Fax: 901-747-1220
Mailing address:
  • Phone: 901-747-1200
  • Fax: 901-747-1220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberE-8519
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number54889
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number201200884
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: