Provider Demographics
NPI:1700854296
Name:DATTA, JASON C (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:C
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 1:2610 N 3RD ST
Mailing Address - Street 2:STE B
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004
Mailing Address - Country:US
Mailing Address - Phone:602-274-7600
Mailing Address - Fax:602-274-7555
Practice Address - Street 1:1255 W RIO SALADO PKWY STE 107
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85281-2892
Practice Address - Country:US
Practice Address - Phone:480-962-0071
Practice Address - Fax:480-962-0590
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO43082207XS0117X
AZ34112207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO802185Medicare ID - Type Unspecified
I32051Medicare UPIN
109711Medicare ID - Type Unspecified