Provider Demographics
NPI:1982961843
Name:DATTA, RAHUL (MD PHD)
Entity Type:Individual
Prefix:DR
First Name:RAHUL
Middle Name:
Last Name:DATTA
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E PENN SQ FL 9
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-3377
Mailing Address - Country:US
Mailing Address - Phone:713-542-2564
Mailing Address - Fax:267-425-9299
Practice Address - Street 1:3500 CIVIC CENTER BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104
Practice Address - Country:US
Practice Address - Phone:215-590-1000
Practice Address - Fax:215-590-2180
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-17
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT54431207K00000X
NJ25MA10427500207K00000X
PAMD465799207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology