Provider Demographics
NPI:1053310920
Name:PURVIN, JAY M (DPM)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:M
Last Name:PURVIN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:336 CEDAR LN
Mailing Address - Street 2:
Mailing Address - City:EAST MEADOW
Mailing Address - State:NY
Mailing Address - Zip Code:11554-2714
Mailing Address - Country:US
Mailing Address - Phone:516-489-1950
Mailing Address - Fax:516-489-6861
Practice Address - Street 1:336 CEDAR LN
Practice Address - Street 2:
Practice Address - City:EAST MEADOW
Practice Address - State:NY
Practice Address - Zip Code:11554-2714
Practice Address - Country:US
Practice Address - Phone:516-489-1950
Practice Address - Fax:516-489-6861
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-21
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNO002971-1213E00000X
NJ25MD00167000213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00406217Medicaid
NJ0758507Medicaid
NYT50924Medicare UPIN
NJ0758507Medicaid
NYP32361Medicare PIN