Provider Demographics
NPI:1164420238
Name:DATTA, PURNENDU PRAKISH (MD)
Entity Type:Individual
Prefix:DR
First Name:PURNENDU
Middle Name:PRAKISH
Last Name:DATTA
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 1:212 E 10TH ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47240-8249
Mailing Address - Country:US
Mailing Address - Phone:812-663-5933
Mailing Address - Fax:812-663-3706
Practice Address - Street 1:212 E 10TH ST
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:IN
Practice Address - Zip Code:47240-8249
Practice Address - Country:US
Practice Address - Phone:812-663-5933
Practice Address - Fax:812-663-3706
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01030095207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN180840Medicare ID - Type Unspecified
INB28516Medicare UPIN