Provider Demographics
NPI:1982666913
Name:DATTA, VASANT (MD)
Entity Type:Individual
Prefix:MR
First Name:VASANT
Middle Name:
Last Name:DATTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 599
Mailing Address - Street 2:
Mailing Address - City:FUNKSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21734-0599
Mailing Address - Country:US
Mailing Address - Phone:301-739-7100
Mailing Address - Fax:301-739-5925
Practice Address - Street 1:340 MILL ST
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-6138
Practice Address - Country:US
Practice Address - Phone:301-739-7100
Practice Address - Fax:301-739-5925
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0018019207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD41251801OtherBC/BC
MD876319OtherMAMSI
MD41251801OtherBC/BC
MD116MC191Medicare ID - Type UnspecifiedMEDICARE