Provider Demographics
NPI:1851592133
Name:DATTA, SOUMITRA (DO)
Entity Type:Individual
Prefix:
First Name:SOUMITRA
Middle Name:
Last Name:DATTA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13355 E 10 MILE RD
Mailing Address - Street 2:MEDICAL EDUCATION OFFICE
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48089-2048
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13355 E 10 MILE RD
Practice Address - Street 2:MEDICAL EDUCATION OFFICE
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48089-2048
Practice Address - Country:US
Practice Address - Phone:586-759-7300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-31
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101015964207R00000X
NY302334207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine