Provider Demographics
NPI:1568535615
Name:DATTA, JYOTI S (MD)
Entity Type:Individual
Prefix:MR
First Name:JYOTI
Middle Name:S
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 1:1045 ATLANTIC #616
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90813
Mailing Address - Country:US
Mailing Address - Phone:562-435-4473
Mailing Address - Fax:562-437-6937
Practice Address - Street 1:1045 ATLANTIC #616
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90813
Practice Address - Country:US
Practice Address - Phone:562-435-4473
Practice Address - Fax:562-437-6937
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA33096207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A330960Medicaid
CAA27035Medicare PIN
CAA33096Medicare UPIN
A27035Medicare UPIN
A33096Medicare ID - Type Unspecified