Provider Demographics
NPI:1477546166
Name:DATTA, SANDEEP (MD)
Entity Type:Individual
Prefix:MR
First Name:SANDEEP
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:PO BOX 116340
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-6340
Mailing Address - Country:US
Mailing Address - Phone:706-860-2701
Mailing Address - Fax:706-860-6484
Practice Address - Street 1:101 PRESTON CT
Practice Address - Street 2:SUITE 103
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-5772
Practice Address - Country:US
Practice Address - Phone:478-745-2385
Practice Address - Fax:478-745-1225
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050473207L00000X, 207LP2900X, 208VP0000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA580628385OtherTRICARE
P00160070OtherRAILROAD MEDICARE
GA000937637FMedicaid
GA000937637IMedicaid
GA670890OtherWELLCARE
GAP01049978OtherRAILROAD MEDICARE
GA000937637DMedicaid
GA000937637HMedicaid
913282OtherBLUE CROSS BLUE SHIELD
GA000937637CMedicaid
GA01652025OtherAMERIGROUP
GA000937637BMedicaid
GA000937637EMedicaid
GA580628385OtherTRICARE
GA670890OtherWELLCARE
GA000937637CMedicaid
GA000937637HMedicaid