Provider Demographics
NPI:1508448564
Name:DUTTA, AMAN (MD)
Entity Type:Individual
Prefix:
First Name:AMAN
Middle Name:
Last Name:DUTTA
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 1:4201 MEDICAL CENTER DRIVE
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050
Mailing Address - Country:US
Mailing Address - Phone:773-299-6591
Mailing Address - Fax:
Practice Address - Street 1:4201 MEDICAL CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050
Practice Address - Country:US
Practice Address - Phone:302-319-2023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-28
Last Update Date:2022-03-22
Deactivation Date:2022-02-24
Deactivation Code:
Reactivation Date:2022-03-22
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program