Healthcare Provider Details

I. General information

NPI: 1316188170
Provider Name (Legal Business Name): VIKAS DATTA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2009
Last Update Date: 03/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 LAC DE VILLE BLVD BUILDING D - SUITE 140
ROCHESTER NY
14618-5647
US

IV. Provider business mailing address

4901 LAC DE VILLE BLVD. BUILDING D - SUITE 140 UNIVERSITY MEDICAL IMAGING
ROCHESTER NY
14618
US

V. Phone/Fax

Practice location:
  • Phone: 585-341-9065
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number270077
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: