Provider Demographics
NPI:1568443059
Name:RAMISETTI, DATTATREYA KUMAR (MD)
Entity type:Individual
Prefix:MR
First Name:DATTATREYA
Middle Name:KUMAR
Last Name:RAMISETTI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:320 SUPERIOR AVE
Mailing Address - Street 2:STE 240
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-2716
Mailing Address - Country:US
Mailing Address - Phone:949-548-8833
Mailing Address - Fax:949-548-2575
Practice Address - Street 1:320 SUPERIOR AVE
Practice Address - Street 2:STE 240
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-2716
Practice Address - Country:US
Practice Address - Phone:949-548-8833
Practice Address - Fax:949-548-2575
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA36545207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A365450Medicaid
CA00A365450Medicaid
A28118Medicare UPIN