Provider Demographics
NPI:1245280544
Name:DUTTA, SUDHIR K (MD)
Entity type:Individual
Prefix:DR
First Name:SUDHIR
Middle Name:K
Last Name:DUTTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6201 GREENLEIGH AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLE RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:21220-2004
Mailing Address - Country:US
Mailing Address - Phone:410-933-6423
Mailing Address - Fax:410-500-4266
Practice Address - Street 1:4924 CAMPBELL BLVD STE 205
Practice Address - Street 2:
Practice Address - City:NOTTINGHAM
Practice Address - State:MD
Practice Address - Zip Code:21236-5914
Practice Address - Country:US
Practice Address - Phone:410-614-5127
Practice Address - Fax:410-616-7651
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD17622207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDCB9279OtherR/R MEDICARE GROUP #
MD371011400Medicaid
MD100006730OtherR/R MEDICARE PROVIDER #
MDS583AI99Medicare PIN
MD371011400Medicaid