MEDICARE: DR. ANKUR DATTA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2080N0001X	Neonatal-Perinatal Medicine Physician	036.128019	IL
2	2080N0001X	Neonatal-Perinatal Medicine Physician	58279	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1750553665
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANKUR DATTA M.D.

Provider Business Mailing Address
First Line	:	PO BOX 776879
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60677-2991
Country	:	US
Telephone Number	:	502-588-9490
Fax Number	:	502-272-5339

Provider Business Practice Location Address
First Line	:	4123 DUTCHMANS LN STE 606
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40207-4725
Country	:	US
Telephone Number	:	502-896-2500
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/31/2008
Last Update Date	:	09/13/2023

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