Provider Demographics
NPI:1497778005
Name:DATTA, SAMYADEV (MD)
Entity Type:Individual
Prefix:
First Name:SAMYADEV
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 1:294 STATE ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-5515
Mailing Address - Country:US
Mailing Address - Phone:201-488-7246
Mailing Address - Fax:201-488-2788
Practice Address - Street 1:294 STATE ST
Practice Address - Street 2:SUITE 1
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-5515
Practice Address - Country:US
Practice Address - Phone:201-488-7246
Practice Address - Fax:201-488-2788
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07161100207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
043931Medicare ID - Type Unspecified