Provider Demographics
NPI:1568688414
Name:DATTA, GAUTAM (MD)
Entity Type:Individual
Prefix:DR
First Name:GAUTAM
Middle Name:
Last Name:DATTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:5000 CEDAR PLAZA PKWY
Mailing Address - Street 2:SUITE 350
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-3854
Mailing Address - Country:US
Mailing Address - Phone:314-843-4333
Mailing Address - Fax:314-843-4856
Practice Address - Street 1:763 S NEW BALLAS RD
Practice Address - Street 2:SUITE 110
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8704
Practice Address - Country:US
Practice Address - Phone:314-843-4333
Practice Address - Fax:314-843-4856
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH350876152084P0800X
MO20070088502084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO209908706Medicaid
MO311391335Medicare PIN