Basic Information
| Provider Information | |||||||||
| NPI: | 1982961843 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DATTA | ||||||||
| FirstName: | RAHUL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD PHD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 100 E PENN SQ FL 9 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191073377 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7135422564 | ||||||||
| FaxNumber: | 2674259299 | ||||||||
| Practice Location | |||||||||
| Address1: | 3500 CIVIC CENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155901000 | ||||||||
| FaxNumber: | 2155902180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2012 | ||||||||
| LastUpdateDate: | 01/17/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X | 54431 | CT | N | Allopathic & Osteopathic Physicians | Allergy & Immunology | 207K00000X | 25MA10427500 | NJ | N | Allopathic & Osteopathic Physicians | Allergy & Immunology | 207K00000X | MD465799 | PA | Y | Allopathic & Osteopathic Physicians | Allergy & Immunology |
No ID Information.