Healthcare Provider Details

I. General information

NPI: 1477546166
Provider Name (Legal Business Name): SANDEEP DATTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 02/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 PRESTON CT SUITE 103
MACON GA
31210-5772
US

IV. Provider business mailing address

PO BOX 116340
ATLANTA GA
30368-6340
US

V. Phone/Fax

Practice location:
  • Phone: 478-745-2385
  • Fax: 478-745-1225
Mailing address:
  • Phone: 706-860-2701
  • Fax: 706-860-6484

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number050473
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number050473
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number050473
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number050473
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: