Provider Demographics
NPI:1164507356
Name:DATTA, NAND S (MD)
Entity Type:Individual
Prefix:
First Name:NAND
Middle Name:S
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 1:3953 BOUTON DRIVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90712
Mailing Address - Country:US
Mailing Address - Phone:562-425-0819
Mailing Address - Fax:562-496-3595
Practice Address - Street 1:5750 DOWNEY AVENUE
Practice Address - Street 2:SUITE #100
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90712
Practice Address - Country:US
Practice Address - Phone:562-630-5870
Practice Address - Fax:562-496-3595
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA25155208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A251550Medicaid
CA00A251550Medicaid
A25155Medicare ID - Type Unspecified