Provider Demographics
NPI:1184712168
Name:DUTTA, SUJAY (MD)
Entity type:Individual
Prefix:
First Name:SUJAY
Middle Name:
Last Name:DUTTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2220 LYNN RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360
Mailing Address - Country:US
Mailing Address - Phone:805-495-1073
Mailing Address - Fax:805-495-5836
Practice Address - Street 1:2220 LYNN RD
Practice Address - Street 2:SUITE 301
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360
Practice Address - Country:US
Practice Address - Phone:805-495-1073
Practice Address - Fax:805-495-5836
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG85674207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G856740Medicaid
CA00G856740Medicaid
CAWG85674AMedicare ID - Type Unspecified