Healthcare Provider Details

I. General information

NPI: 1427161801
Provider Name (Legal Business Name): KRISHNA DATTA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 08/24/2021
Certification Date: 08/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 LAKE AVE
FORT WAYNE IN
46805-5100
US

IV. Provider business mailing address

PO BOX 2505
FORT WAYNE IN
46801-2505
US

V. Phone/Fax

Practice location:
  • Phone: 260-426-5431
  • Fax:
Mailing address:
  • Phone: 260-432-2297
  • Fax: 260-436-4380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number01061557
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01061557A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: