Provider Demographics
NPI:1790860898
Name:VASANT DATTA MD LLC
Entity Type:Organization
Organization Name:VASANT DATTA MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:VASANT
Authorized Official - Middle Name:
Authorized Official - Last Name:DATTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-739-7100
Mailing Address - Street 1:340 MILL ST
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21740-6138
Mailing Address - Country:US
Mailing Address - Phone:301-739-7100
Mailing Address - Fax:301-739-5925
Practice Address - Street 1:9727 PEMBROKE DR
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-1568
Practice Address - Country:US
Practice Address - Phone:240-675-1231
Practice Address - Fax:301-714-0011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0018019261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care