Basic Information
| Provider Information | |||||||||
| NPI: | 1659336485 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DATTA | ||||||||
| FirstName: | SUBHAJIT | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3124 BEAN OLLER RD | ||||||||
| Address2: | |||||||||
| City: | DELAWARE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430159220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403696516 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1040 DELAWARE AVE | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403837980 | ||||||||
| FaxNumber: | 7403833040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2006 | ||||||||
| LastUpdateDate: | 04/05/2013 | ||||||||
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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 | 208G00000X | 092044 | OH | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 020034670 | 01 | RAILROAD MEDICARE | OTHER |