Provider Demographics
NPI:1659452720
Name:DUTTA, SANJEEV (MD MA FRCSC)
Entity Type:Individual
Prefix:DR
First Name:SANJEEV
Middle Name:
Last Name:DUTTA
Suffix:
Gender:M
Credentials:MD MA FRCSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:780 WELCH ROAD STE 206
Mailing Address - Street 2:
Mailing Address - City:STANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:94305
Mailing Address - Country:US
Mailing Address - Phone:650-723-6439
Mailing Address - Fax:
Practice Address - Street 1:780 WELCH ROAD STE 206
Practice Address - Street 2:
Practice Address - City:STANFORD
Practice Address - State:CA
Practice Address - Zip Code:94305
Practice Address - Country:US
Practice Address - Phone:650-723-6439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA881682086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A881680OtherMEDICAL
CAOTH000Medicare UPIN