Provider Demographics
NPI:1417162801
Name:DATTA, TEJWANT SINGH (MD)
Entity Type:Individual
Prefix:DR
First Name:TEJWANT
Middle Name:SINGH
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:PO BOX 402924
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-2924
Mailing Address - Country:US
Mailing Address - Phone:804-533-0220
Mailing Address - Fax:804-533-0230
Practice Address - Street 1:9460 AMDERDALE DRIVE SUITE E
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23236
Practice Address - Country:US
Practice Address - Phone:804-533-0220
Practice Address - Fax:804-533-0230
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101246677208600000X, 207RB0002X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207RB0002XAllopathic & Osteopathic PhysiciansInternal MedicineObesity Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVAA102362OtherMEDICARE
VA1417162801Medicaid
VAVAA102362OtherMEDICARE