Provider Demographics
NPI:1225054679
Name:DUTTA, SWATI (MD)
Entity Type:Individual
Prefix:
First Name:SWATI
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 1:1420 STEPHENSON HWY
Mailing Address - Street 2:SUITE 400-CREDENTIALING
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1189
Mailing Address - Country:US
Mailing Address - Phone:248-581-5974
Mailing Address - Fax:248-581-5640
Practice Address - Street 1:5301 EAST HURON RIVER DRIVE
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-0995
Practice Address - Country:US
Practice Address - Phone:734-712-3595
Practice Address - Fax:734-712-5344
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2013-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0732512085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4668311Medicaid
G07547Medicare UPIN
MIP07550004Medicare ID - Type Unspecified