Provider Demographics
NPI:1225184765
Name:DATTA, GAURAV (MD)
Entity Type:Individual
Prefix:
First Name:GAURAV
Middle Name:
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 1:7510 FORTALEZA AVE
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95757-1769
Mailing Address - Country:US
Mailing Address - Phone:414-336-8677
Mailing Address - Fax:925-954-6958
Practice Address - Street 1:7510 FORTALEZA AVE
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95757-1769
Practice Address - Country:US
Practice Address - Phone:414-336-8677
Practice Address - Fax:925-954-6958
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI51523-20207R00000X
WI51523-020208M00000X
CAC153705207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist