Provider Demographics
NPI:1558689539
Name:DATTA, JASHODEEP (MD)
Entity Type:Individual
Prefix:
First Name:JASHODEEP
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 1:1475 NW 12TH AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136-1002
Mailing Address - Country:US
Mailing Address - Phone:305-243-4902
Mailing Address - Fax:305-243-4907
Practice Address - Street 1:1475 NW 12TH AVE FL 2
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1002
Practice Address - Country:US
Practice Address - Phone:305-243-4902
Practice Address - Fax:305-243-4907
Is Sole Proprietor?:No
Enumeration Date:2010-05-14
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT197449208600000X, 390200000X
FLME1417172086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program