Provider Demographics
NPI:1295830420
Name:PURNENDUE P DATTA MD
Entity Type:Organization
Organization Name:PURNENDUE P DATTA MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PURNENDUE
Authorized Official - Middle Name:P
Authorized Official - Last Name:DATTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-663-5933
Mailing Address - Street 1:PO BOX 68952
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-0952
Mailing Address - Country:US
Mailing Address - Phone:317-802-6319
Mailing Address - Fax:317-870-0499
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01030095207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN180840Medicare ID - Type UnspecifiedMCARE #