Healthcare Provider Details

I. General information

NPI: 1205872421
Provider Name (Legal Business Name): BHUPINDER DATTA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 06/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

699 RURAL AVE
WILLIAMSPORT PA
17701
US

IV. Provider business mailing address

PO BOX 75113
BALTIMORE MD
21275-5113
US

V. Phone/Fax

Practice location:
  • Phone: 570-321-2340
  • Fax: 904-346-0113
Mailing address:
  • Phone: 304-422-1666
  • Fax: 904-346-0113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD038778L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: