Provider Demographics
NPI:1770521445
Name:BUTTY, SABAH DAVID (MD)
Entity type:Individual
Prefix:
First Name:SABAH
Middle Name:DAVID
Last Name:BUTTY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:250 E DAY RD STE 300
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-3471
Practice Address - Country:US
Practice Address - Phone:574-968-0283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01056204A2085R0204X
IN010562042085R0202X, 2085R0204X
WI693122085R0202X
IL0361188652085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000244109OtherANTHEM PTAN
IN200394870Medicaid
IN300136652OtherRAILROAD MEDICARE
IN959090Z8OtherMEDICARE PTAN
INP00195786OtherRAILROAD MEDICARE
IN200394870Medicaid