Provider Demographics
NPI:1427161801
Name:DATTA, KRISHNA (MD)
Entity type:Individual
Prefix:
First Name:KRISHNA
Middle Name:
Last Name:DATTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2505
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46801-2505
Mailing Address - Country:US
Mailing Address - Phone:260-432-2297
Mailing Address - Fax:260-436-4380
Practice Address - Street 1:2121 LAKE AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5100
Practice Address - Country:US
Practice Address - Phone:260-426-5431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01061557208M00000X
IN01061557A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000487981OtherANTHEM
P00417461OtherRAILROAD
OH2679936Medicaid
IN200830440Medicaid
INI64766Medicare UPIN
INM400063955Medicare PIN
P00417461OtherRAILROAD