Basic Information
Provider Information | |||||||||
NPI: | 1821062290 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DATTA | ||||||||
FirstName: | DEVIN | ||||||||
MiddleName: | KUMAR | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2222 S HARBOR CITY BLVD STE 610 | ||||||||
Address2: |   | ||||||||
City: | MELBOURNE | ||||||||
State: | FL | ||||||||
PostalCode: | 329015591 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3217237716 | ||||||||
FaxNumber: | 3217230604 | ||||||||
Practice Location | |||||||||
Address1: | 2222 S HARBOR CITY BLVD | ||||||||
Address2: | SUITE 610 | ||||||||
City: | MELBOURNE | ||||||||
State: | FL | ||||||||
PostalCode: | 329015594 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3217237716 | ||||||||
FaxNumber: | 3217230604 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/14/2006 | ||||||||
LastUpdateDate: | 02/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/21/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | ME82856 | FL | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 265084301 | 05 | FL |   | MEDICAID | OU297 | 01 | FL | MEDICARE HF | OTHER | 03336 | 01 | FL | BCBS | OTHER |