Provider Demographics
NPI:1881333961
Name:DUTTA, SOMA (MD)
Entity type:Individual
Prefix:
First Name:SOMA
Middle Name:
Last Name:DUTTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1688 FORSYTHE TRL
Mailing Address - Street 2:
Mailing Address - City:COLLIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38017-9770
Mailing Address - Country:US
Mailing Address - Phone:901-605-2201
Mailing Address - Fax:
Practice Address - Street 1:1500 S FAIRFIELD AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1782
Practice Address - Country:US
Practice Address - Phone:901-605-2201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-27
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.080264207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine