1164507356 NPI number — NAND S DATTA MD

Table of content: NAND S DATTA MD (NPI 1164507356)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164507356 NPI number — NAND S DATTA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DATTA
Provider First Name:
NAND
Provider Middle Name:
S
Provider Name Prefix Text:
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:
1164507356
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3953 BOUTON DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKEWOOD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90712
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-425-0819
Provider Business Mailing Address Fax Number:
562-496-3595

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5750 DOWNEY AVENUE
Provider Second Line Business Practice Location Address:
SUITE #100
Provider Business Practice Location Address City Name:
LAKEWOOD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-630-5870
Provider Business Practice Location Address Fax Number:
562-496-3595
Provider Enumeration Date:
10/26/2006

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: 208800000X , with the licence number:  A25155 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00A251550 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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