Provider Demographics
NPI:1306070552
Name:BUTTRUM, MANDY YVONNE (MD)
Entity type:Individual
Prefix:DR
First Name:MANDY
Middle Name:YVONNE
Last Name:BUTTRUM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 33269
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85067-3269
Mailing Address - Country:US
Mailing Address - Phone:702-616-5801
Mailing Address - Fax:
Practice Address - Street 1:660 S GREEN VALLEY PKWY STE 130
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-0431
Practice Address - Country:US
Practice Address - Phone:702-470-2800
Practice Address - Fax:702-478-9354
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-02
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NV15199207Q00000X
FLME112957207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLGJ654ZMedicare UPIN