Individual
MR. SANDEEP DATTA
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
101 PRESTON CT, SUITE 103, MACON, GA 31210-5772
(478) 745-2385
(478) 745-1225
Mailing address
PO BOX 116340, ATLANTA, GA 30368-6340
(706) 860-2701
(706) 860-6484
Taxonomy
Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
050473
GA
207LP2900X
Pain Medicine (Anesthesiology) Physician
050473
GA
208VP0000X
Pain Medicine Physician
050473
GA
208VP0014X
Interventional Pain Medicine Physician
Primary
050473
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000937637B
—
GA
05
—
000937637C
—
GA
05
—
000937637D
—
GA
05
—
000937637E
—
GA
05
—
000937637F
—
GA
05
—
000937637H
—
GA
05
—
000937637I
—
GA
01
—
01652025
AMERIGROUP
GA
01
—
580628385
TRICARE
GA
01
—
670890
WELLCARE
GA
01
—
913282
BLUE CROSS BLUE SHIELD
—
01
—
P00160070
RAILROAD MEDICARE
—
01
—
P01049978
RAILROAD MEDICARE
GA
Enumeration date
08/26/2005
Last updated
02/16/2017
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