Provider Demographics
NPI:1942884291
Name:DATLA, SANJANA
Entity Type:Individual
Prefix:
First Name:SANJANA
Middle Name:
Last Name:DATLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4209 ST OH-44
Mailing Address - Street 2:
Mailing Address - City:ROOTSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44272
Mailing Address - Country:US
Mailing Address - Phone:800-686-2511
Mailing Address - Fax:
Practice Address - Street 1:4209 OH-44
Practice Address - Street 2:
Practice Address - City:ROOTSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44272-4427
Practice Address - Country:US
Practice Address - Phone:513-526-5145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-11
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program