Healthcare Provider Details

I. General information

NPI: 1164420238
Provider Name (Legal Business Name): PURNENDU PRAKISH DATTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 E 10TH ST
GREENSBURG IN
47240-8249
US

IV. Provider business mailing address

212 E 10TH ST
GREENSBURG IN
47240-8249
US

V. Phone/Fax

Practice location:
  • Phone: 812-663-5933
  • Fax: 812-663-3706
Mailing address:
  • Phone: 812-663-5933
  • Fax: 812-663-3706

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01030095
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: