Provider Demographics
NPI:1154309086
Name:BUTT, SHYLA IMDAD (MD)
Entity type:Individual
Prefix:DR
First Name:SHYLA
Middle Name:IMDAD
Last Name:BUTT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHYLA
Other - Middle Name:
Other - Last Name:KIFAYAT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1400 BRYAN DRIVE
Mailing Address - Street 2:SUITE 211
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701
Mailing Address - Country:US
Mailing Address - Phone:580-924-2424
Mailing Address - Fax:580-924-2425
Practice Address - Street 1:1400 BRYAN DRIVE
Practice Address - Street 2:SUITE 211
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701
Practice Address - Country:US
Practice Address - Phone:580-924-2424
Practice Address - Fax:580-924-2425
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23789174400000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered174400000XOther Service ProvidersSpecialist
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKI06707Medicare UPIN