Basic Information
| Provider Information | |||||||||
| NPI: | 1245280544 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DUTTA | ||||||||
| FirstName: | SUDHIR | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2401 W BELVEDERE AVE | ||||||||
| Address2: | ATTN: GASTROENTEROLOGY | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212155216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106014536 | ||||||||
| FaxNumber: | 4106015757 | ||||||||
| Practice Location | |||||||||
| Address1: | 2411 W BELVEDERE AVE | ||||||||
| Address2: | SUITE305 | ||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212155228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106014536 | ||||||||
| FaxNumber: | 4106015757 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 04/07/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | D17622 | MD | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0100X | D17622 | MD | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 100006730 | 01 | MD | R/R MEDICARE PROVIDER # | OTHER | 371011400 | 05 | MD | MEDICAID | CB9279 | 01 | MD | R/R MEDICARE GROUP # | OTHER |