Basic Information
| Provider Information | |||||||||
| NPI: | 1477546166 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DATTA | ||||||||
| FirstName: | SANDEEP | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 116340 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303686340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068602701 | ||||||||
| FaxNumber: | 7068606484 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 PRESTON CT | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312105772 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787452385 | ||||||||
| FaxNumber: | 4787451225 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2005 | ||||||||
| LastUpdateDate: | 02/16/2017 | ||||||||
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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 | 207L00000X | 050473 | GA | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | 050473 | GA | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 208VP0000X | 050473 | GA | N | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine | 208VP0014X | 050473 | GA | Y | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 580628385 | 01 | GA | TRICARE | OTHER | P00160070 | 01 | RAILROAD MEDICARE | OTHER | 000937637F | 05 | GA | MEDICAID | 000937637I | 05 | GA | MEDICAID | 670890 | 01 | GA | WELLCARE | OTHER | P01049978 | 01 | GA | RAILROAD MEDICARE | OTHER | 000937637D | 05 | GA | MEDICAID | 000937637H | 05 | GA | MEDICAID | 913282 | 01 | BLUE CROSS BLUE SHIELD | OTHER | 000937637C | 05 | GA | MEDICAID | 01652025 | 01 | GA | AMERIGROUP | OTHER | 000937637B | 05 | GA | MEDICAID | 000937637E | 05 | GA | MEDICAID |