Provider Demographics
NPI:1952875064
Name:OM DATTA PLLC
Entity type:Organization
Organization Name:OM DATTA PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:VENKATESH
Authorized Official - Middle Name:
Authorized Official - Last Name:MADHAV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:469-476-7810
Mailing Address - Street 1:5040 TENNYSON PKWY
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-3002
Mailing Address - Country:US
Mailing Address - Phone:469-476-7810
Mailing Address - Fax:469-574-7840
Practice Address - Street 1:5040 TENNYSON PKWY
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75024-3002
Practice Address - Country:US
Practice Address - Phone:469-476-7810
Practice Address - Fax:469-574-7840
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OM DATTA PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-01-11
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty