Provider Demographics
NPI:1902242597
Name:DATTA, RESHAM (MD)
Entity type:Individual
Prefix:
First Name:RESHAM
Middle Name:
Last Name:DATTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:RESHAM
Other - Middle Name:
Other - Last Name:MEHORTRA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:110 BEECH HILL CRES
Mailing Address - Street 2:
Mailing Address - City:PITTSFORD
Mailing Address - State:NY
Mailing Address - Zip Code:14534-4213
Mailing Address - Country:US
Mailing Address - Phone:516-749-2121
Mailing Address - Fax:
Practice Address - Street 1:110 BEECH HILL CRES
Practice Address - Street 2:
Practice Address - City:PITTSFORD
Practice Address - State:NY
Practice Address - Zip Code:14534-4213
Practice Address - Country:US
Practice Address - Phone:516-749-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-22
Last Update Date:2022-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN58003207L00000X
FLME142272207LP2900X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine