Healthcare Provider Details

I. General information

NPI: 1083903975
Provider Name (Legal Business Name): SIMANTA DUTTA M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2011
Last Update Date: 01/17/2024
Certification Date: 01/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

844 KEMPSVILLE RD STE 212
NORFOLK VA
23502-3927
US

IV. Provider business mailing address

PO BOX 602658
CHARLOTTE NC
28260-2658
US

V. Phone/Fax

Practice location:
  • Phone: 757-261-5977
  • Fax: 757-275-9913
Mailing address:
  • Phone: 336-716-5599
  • Fax: 336-716-3202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number2011-00997
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number0101278090
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number2011-00997
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number0101278090
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: