Healthcare Provider Details

I. General information

NPI: 1457347601
Provider Name (Legal Business Name): RAJIV DATTA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2005
Last Update Date: 05/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 S CENTRAL AVE
VALLEY STREAM NY
11580-5443
US

IV. Provider business mailing address

1 HEALTHY WAY ATTN: PHYSICIAN BILLING
OCEANSIDE NY
11572-1551
US

V. Phone/Fax

Practice location:
  • Phone: 516-632-3300
  • Fax: 516-632-3355
Mailing address:
  • Phone: 516-255-1616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number201327
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: