Provider Demographics
NPI:1053342212
Name:DUTTA, DURBA (MD)
Entity type:Individual
Prefix:DR
First Name:DURBA
Middle Name:
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 1:325 DISTEL CIRCLE
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CO
Mailing Address - Zip Code:94002-1408
Mailing Address - Country:US
Mailing Address - Phone:707-521-4480
Mailing Address - Fax:707-521-4460
Practice Address - Street 1:3883 AIRWAY DR STE 100
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403
Practice Address - Country:US
Practice Address - Phone:707-521-4480
Practice Address - Fax:707-521-4460
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG87087208D00000X
CARHL001613492085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
3845061OtherCIGNA
CAG87087OtherSTATE MEDICAL LICENSE
CARHL00161349OtherCALIFORNIA XRAY BOARD
CARHL00161349OtherCALIFORNIA XRAY BOARD
CACA298544OtherMEDICARE
CAP02029212OtherRAILROAD
CACA298543OtherMEDICARE