Provider Demographics
NPI:1174563597
Name:BUTO-COLLETTI, CASSANDRA (DO)
Entity type:Individual
Prefix:MS
First Name:CASSANDRA
Middle Name:
Last Name:BUTO-COLLETTI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-434-8505
Mailing Address - Fax:
Practice Address - Street 1:6 RICHLAND MEDICAL PARK DR STE 2100
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6864
Practice Address - Country:US
Practice Address - Phone:803-434-8505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC83361207RC0000X, 207RA0001X
VA0102204524207RC0000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0001XAllopathic & Osteopathic PhysiciansInternal MedicineAdvanced Heart Failure and Transplant Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC933619Medicaid
NY6510DZMedicare ID - Type Unspecified