Provider Demographics
NPI:1164735338
Name:DATTA, INDERPREET KAUR (OD)
Entity Type:Individual
Prefix:
First Name:INDERPREET
Middle Name:KAUR
Last Name:DATTA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:INDERPREET
Other - Middle Name:KAUR
Other - Last Name:GROVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:16025 DRUMONE RD
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-5533
Mailing Address - Country:US
Mailing Address - Phone:804-530-3937
Mailing Address - Fax:804-530-3934
Practice Address - Street 1:204 JOHNSON CREEK DR
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:VA
Practice Address - Zip Code:23836-2840
Practice Address - Country:US
Practice Address - Phone:804-530-3937
Practice Address - Fax:804-530-3934
Is Sole Proprietor?:No
Enumeration Date:2010-07-16
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001963152WC0802X, 152WP0200X, 152WV0400X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVV034AMedicare PIN