Provider Demographics
NPI:1164489860
Name:PURANIK, PRAKASH N (MD)
Entity Type:Individual
Prefix:DR
First Name:PRAKASH
Middle Name:N
Last Name:PURANIK
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 1:546 S BROAD ST
Mailing Address - Street 2:UNIT 2 E
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06450-6600
Mailing Address - Country:US
Mailing Address - Phone:203-237-1054
Mailing Address - Fax:
Practice Address - Street 1:546 S BROAD ST
Practice Address - Street 2:UNIT 2 E
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450-6600
Practice Address - Country:US
Practice Address - Phone:203-237-1054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT022155207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001221555Medicaid
CTB83443Medicare UPIN
CT001221555Medicaid