Healthcare Provider Details

I. General information

NPI: 1093073090
Provider Name (Legal Business Name): DEBAJYOTI DATTA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2012
Last Update Date: 05/14/2025
Certification Date: 05/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 PARNASSUS AVE FL 4
SAN FRANCISCO CA
94143-2202
US

IV. Provider business mailing address

400 PARNASSUS AVE FL 4
SAN FRANCISCO CA
94143-2202
US

V. Phone/Fax

Practice location:
  • Phone: 415-353-2421
  • Fax: 415-353-2467
Mailing address:
  • Phone: 415-353-2421
  • Fax: 415-353-2467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License NumberA137105
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: