Provider Demographics
NPI:1821679820
Name:DUTTA, GAURAV N/A (DPT)
Entity Type:Individual
Prefix:MR
First Name:GAURAV
Middle Name:N/A
Last Name:DUTTA
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2836 ELM ST
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11572-1915
Mailing Address - Country:US
Mailing Address - Phone:516-495-0764
Mailing Address - Fax:
Practice Address - Street 1:1554 NORTHERN BLVD FL 3
Practice Address - Street 2:
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-3054
Practice Address - Country:US
Practice Address - Phone:646-733-4737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-20
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030895225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist