Provider Demographics
NPI:1861652026
Name:UJJWAL K DATTA DPM
Entity Type:Organization
Organization Name:UJJWAL K DATTA DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:UJJWAL
Authorized Official - Middle Name:K
Authorized Official - Last Name:DATTA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:646-552-6823
Mailing Address - Street 1:9737 63RD RD
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-1642
Mailing Address - Country:US
Mailing Address - Phone:732-442-3668
Mailing Address - Fax:
Practice Address - Street 1:491 NEW BRUNSWICK AVE
Practice Address - Street 2:
Practice Address - City:PERTH AMBOY
Practice Address - State:NJ
Practice Address - Zip Code:08861-3653
Practice Address - Country:US
Practice Address - Phone:732-442-3668
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-11
Last Update Date:2009-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ5326930002332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0029157Medicaid
NJ0029157Medicaid