Provider Demographics
NPI:1396822979
Name:DUTTA, EAMON K (MD)
Entity Type:Individual
Prefix:
First Name:EAMON
Middle Name:K
Last Name:DUTTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2150 PEACHFORD RD
Mailing Address - Street 2:STE A
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30338-6521
Mailing Address - Country:US
Mailing Address - Phone:770-674-0553
Mailing Address - Fax:770-674-0554
Practice Address - Street 1:2150 PEACHFORD RD
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30338-6520
Practice Address - Country:US
Practice Address - Phone:770-455-3200
Practice Address - Fax:770-458-1594
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA0465932084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA26BDJWGMedicare ID - Type Unspecified
GAH17562Medicare UPIN