Provider Demographics
NPI:1588693139
Name:DUTTA, ELLEN JOY (MD)
Entity type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:JOY
Last Name:DUTTA
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:LAHEY PROVIDER ENROLLMENT
Mailing Address - Street 2:41 MALL ROAD
Mailing Address - City:BURLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01805-0001
Mailing Address - Country:US
Mailing Address - Phone:781-744-8085
Mailing Address - Fax:781-744-5433
Practice Address - Street 1:LAHEY HOSPITAL AND MEDICAL CENTER
Practice Address - Street 2:41 MALL ROAD
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01805
Practice Address - Country:US
Practice Address - Phone:781-744-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA234028207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
1829996 1OtherCIGNA PAL
TX0090HUOtherBLUE CROSS BLUE SHIELD
TX00927FOtherMEDICARE ID
TX4218788OtherBLUE LINK
TX7543296OtherAETNA
TX1829996 1OtherCIGNA PAL
TX0090HUOtherBLUE CROSS BLUE SHIELD
TX1829996 1OtherCIGNA PAL