Provider Demographics
NPI:1740400191
Name:DATTA, VIVEKANAND (MD PHD)
Entity Type:Individual
Prefix:
First Name:VIVEKANAND
Middle Name:
Last Name:DATTA
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11767 SKYLARK RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20871
Mailing Address - Country:US
Mailing Address - Phone:901-786-4755
Mailing Address - Fax:
Practice Address - Street 1:8700 BEVERLY BLVD.
Practice Address - Street 2:CEDAR SINAI
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048
Practice Address - Country:US
Practice Address - Phone:310-423-6941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN390200000X207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology