Provider Demographics
NPI:1801820113
Name:DATTATREYA, RAJIV (MD)
Entity Type:Individual
Prefix:DR
First Name:RAJIV
Middle Name:
Last Name:DATTATREYA
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 1:2021 N MACARTHUR BLVD
Mailing Address - Street 2:STE 150
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75061-2219
Mailing Address - Country:US
Mailing Address - Phone:972-253-2560
Mailing Address - Fax:972-253-4218
Practice Address - Street 1:10260 N CENTRAL EXPY STE 100N
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-3437
Practice Address - Country:US
Practice Address - Phone:214-363-5535
Practice Address - Fax:214-368-2760
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL0117207RE0101X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0375503 04Medicaid
8 M2063OtherBC/BS
TX037550303Medicaid
TX8J7489OtherMEDICARE NUMBER
TX8L10293OtherMEDICARE PTAN
G63322Medicare UPIN