Basic Information
| Provider Information | |||||||||
| NPI: | 1649428897 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUTTA | ||||||||
| FirstName: | UTPAL | ||||||||
| MiddleName: | KANTI | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2424 | ||||||||
| Address2: | |||||||||
| City: | PRINCE FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206782424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105352085 | ||||||||
| FaxNumber: | 4105350404 | ||||||||
| Practice Location | |||||||||
| Address1: | 130 HOSPITAL RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | PRINCE FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206784057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105354333 | ||||||||
| FaxNumber: | 4105353260 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2008 | ||||||||
| LastUpdateDate: | 12/06/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | D70833 | MD | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 01366238 | 01 | AMERIGROUP | OTHER | 1649428897 | 01 | TRICARE | OTHER | 1649428897 | 01 | KAISER PERMANENTE | OTHER | 1649428897 | 01 | CARE IMPROVEMENT PLUS | OTHER | 1649428897 | 01 | MARYLAND PHYSICIANS CARE | OTHER | 1649428897 | 01 | COVENTRY HEALTH CARE OF DELAWARE | OTHER | 522300606 | 01 | MD | PATUXENT NEPHROLOGY ASSOCIATES, LLC | OTHER | 1649428897 | 01 | CIGNA | OTHER | 1649428897 | 01 | UNITED HEALTHCARE, MAMSI, MDIPA, OPTIMUM CHOICE | OTHER | F117 AND 0J48PA | 01 | CAREFIRST BLUECROSS BLUESHIELD | OTHER | 1649428897 | 01 | MULTIPLAN, PHCS | OTHER | 418952301 | 05 | MD | MEDICAID |