Provider Demographics
NPI:1003069535
Name:DUTTA, SUPARNA (MD)
Entity Type:Individual
Prefix:
First Name:SUPARNA
Middle Name:
Last Name:DUTTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 W VAN BUREN ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-5500
Mailing Address - Country:US
Mailing Address - Phone:312-942-4200
Mailing Address - Fax:312-942-3568
Practice Address - Street 1:1700 W VAN BUREN ST
Practice Address - Street 2:SUITE 500
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-5500
Practice Address - Country:US
Practice Address - Phone:312-942-4200
Practice Address - Fax:312-942-3568
Is Sole Proprietor?:No
Enumeration Date:2008-10-28
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA238252207R00000X
FLME110370207R00000X
IL036-132645207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine