Healthcare Provider Details

I. General information

NPI: 1033735931
Provider Name (Legal Business Name): GAURAV DATTA MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2020
Last Update Date: 01/13/2023
Certification Date: 01/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7510 FORTALEZA AVE
ELK GROVE CA
95757-1769
US

IV. Provider business mailing address

7510 FORTALEZA AVE
ELK GROVE CA
95757-1769
US

V. Phone/Fax

Practice location:
  • Phone: 414-336-8677
  • Fax: 925-954-6958
Mailing address:
  • Phone: 414-336-8677
  • Fax: 925-954-6958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number
License Number State

VIII. Authorized Official

Name: GAURAV DATTA
Title or Position: OWNER
Credential: MD
Phone: 414-336-8677