Provider Demographics
NPI:1891026126
Name:DUTTA, GAURAV (MD)
Entity type:Individual
Prefix:
First Name:GAURAV
Middle Name:
Last Name:DUTTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1551 DOCTORS DR
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-4139
Mailing Address - Country:US
Mailing Address - Phone:706-880-7222
Mailing Address - Fax:706-880-7223
Practice Address - Street 1:1551 DOCTORS DR
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-4139
Practice Address - Country:US
Practice Address - Phone:706-880-7222
Practice Address - Fax:706-880-7223
Is Sole Proprietor?:No
Enumeration Date:2010-01-27
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS24420207RP1001X
GA92087207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease