1477546166 NPI number — MR. SANDEEP DATTA MD

Table of content: MR. SANDEEP DATTA MD (NPI 1477546166)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477546166 NPI number — MR. SANDEEP DATTA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DATTA
Provider First Name:
SANDEEP
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477546166
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/16/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 116340
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30368-6340
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-860-2701
Provider Business Mailing Address Fax Number:
706-860-6484

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 PRESTON CT
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
MACON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31210-5772
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-745-2385
Provider Business Practice Location Address Fax Number:
478-745-1225
Provider Enumeration Date:
08/26/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  050473 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207LP2900X , with the licence number: 050473 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0000X , with the licence number: 050473 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208VP0014X , with the licence number: 050473 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 580628385 . This is a "TRICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: P00160070 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000937637F , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000937637I , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 670890 . This is a "WELLCARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: P01049978 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000937637D , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000937637H , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 913282 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000937637C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01652025 . This is a "AMERIGROUP" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000937637B , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000937637E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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