Provider Demographics
NPI:1144586983
Name:DASGUPTA, AMITAVA MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:AMITAVA
Middle Name:MICHAEL
Last Name:DASGUPTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 E 11TH ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:KY
Mailing Address - Zip Code:41071-2203
Mailing Address - Country:US
Mailing Address - Phone:859-655-6100
Mailing Address - Fax:
Practice Address - Street 1:1401 MADISON AVE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:KY
Practice Address - Zip Code:41011-3313
Practice Address - Country:US
Practice Address - Phone:859-655-6100
Practice Address - Fax:573-882-6228
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-05
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY57201207QG0300X, 207Q00000X
MO201636529207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY57201OtherKY LICENSE