Provider Demographics
NPI:1750553665
Name:DATTA, ANKUR (MD)
Entity type:Individual
Prefix:DR
First Name:ANKUR
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 776879
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-2991
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5339
Practice Address - Street 1:4123 DUTCHMANS LN STE 606
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4725
Practice Address - Country:US
Practice Address - Phone:502-896-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-31
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.1280192080N0001X
KY582792080N0001X
WI626442080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036.128019Medicaid