Healthcare Provider Details

I. General information

NPI: 1275096190
Provider Name (Legal Business Name): SUDARSHANA DATTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2019
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3623 J DEWEY GRAY CIR STE 202
AUGUSTA GA
30909-6554
US

IV. Provider business mailing address

3623 J DEWEY GRAY CIR STE 202
AUGUSTA GA
30909-6554
US

V. Phone/Fax

Practice location:
  • Phone: 706-863-8155
  • Fax: 706-863-8175
Mailing address:
  • Phone: 706-863-8155
  • Fax: 706-863-8175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number104930
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: