MEDICARE: GOURI DATTA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	38554	MA
2	2084P0800X	Psychiatry Physician	38554	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1528054889
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GOURI DATTA MD

Provider Business Mailing Address
First Line	:	41 MALL RD
Second Line	:	LAHEY CLINIC, INC.
City	:	BURLINGTON
State	:	MA
Zip	:	01805-0001
Country	:	US
Telephone Number	:	617-548-0184
Fax Number	:	781-744-5235

Provider Business Practice Location Address
First Line	:	41 MALL RD
Second Line	:
City	:	BURLINGTON
State	:	MA
Zip	:	01805-0001
Country	:	US
Telephone Number	:	617-548-0184
Fax Number	:	781-744-5235

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/22/2005
Last Update Date	:	06/01/2026

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