Healthcare Provider Details

I. General information

NPI: 1366678567
Provider Name (Legal Business Name): SUDIP DATTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2009
Last Update Date: 08/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

639 TANYA COURT DR
SAINT LOUIS MO
63129-2555
US

IV. Provider business mailing address

639 TANYA COURT DR
SAINT LOUIS MO
63129-2555
US

V. Phone/Fax

Practice location:
  • Phone: 270-804-8025
  • Fax:
Mailing address:
  • Phone: 270-804-8025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberTP647
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberTP647
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License NumberTP647
License Number StateKY
# 4
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number2012029909
License Number StateMO
# 5
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number2012029909
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: