Provider Demographics
NPI:1841231628
Name:GOURI DATTA MD PC
Entity Type:Organization
Organization Name:GOURI DATTA MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GOURI
Authorized Official - Middle Name:
Authorized Official - Last Name:DATTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:978-685-8800
Mailing Address - Street 1:451 ANDOVER ST
Mailing Address - Street 2:SUITE 195
Mailing Address - City:NORTH ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01845-5044
Mailing Address - Country:US
Mailing Address - Phone:978-685-8800
Mailing Address - Fax:978-685-8808
Practice Address - Street 1:451 ANDOVER ST
Practice Address - Street 2:SUITE 195
Practice Address - City:NORTH ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01845-5044
Practice Address - Country:US
Practice Address - Phone:978-685-8800
Practice Address - Fax:978-685-8808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM21813Medicare ID - Type Unspecified