Provider Demographics
NPI:1326549957
Name:DUTTA, SUSHIL
Entity Type:Individual
Prefix:
First Name:SUSHIL
Middle Name:
Last Name:DUTTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 BERKSHIRE AVE
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:CA
Mailing Address - Zip Code:92223-3129
Mailing Address - Country:US
Mailing Address - Phone:909-363-5921
Mailing Address - Fax:
Practice Address - Street 1:82955 AVENUE 48
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-6757
Practice Address - Country:US
Practice Address - Phone:760-342-2031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-28
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA77850183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist