Healthcare Provider Details

I. General information

NPI: 1629246137
Provider Name (Legal Business Name): EAMON DUTTA, MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2008
Last Update Date: 02/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2150 PEACHFORD RD SUITE A
ATLANTA GA
30338-6520
US

IV. Provider business mailing address

2150 PEACHFORD RD SUITE A
ATLANTA GA
30338-6520
US

V. Phone/Fax

Practice location:
  • Phone: 770-344-9818
  • Fax: 770-458-1596
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number046593
License Number StateGA

VIII. Authorized Official

Name: KENNETH R WARNER
Title or Position: BILLING
Credential:
Phone: 770-458-1594