Healthcare Provider Details

I. General information

NPI: 1023156601
Provider Name (Legal Business Name): MEDICAL PSYCHIATRIC PRCATICE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 N BROADWAY
WHITE PLAINS NY
10603-3217
US

IV. Provider business mailing address

9 OVERHILL RD
SCARSDALE NY
10583-5307
US

V. Phone/Fax

Practice location:
  • Phone: 914-723-3247
  • Fax: 914-723-4211
Mailing address:
  • Phone: 914-723-3247
  • Fax: 914-723-4211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number138997
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. MOITRI NATH DATTA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 914-723-3247