Provider Demographics
NPI:1275578759
Name:PURI, VIRENDER KRISHAN (MD)
Entity Type:Individual
Prefix:
First Name:VIRENDER
Middle Name:KRISHAN
Last Name:PURI
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 1:2200 JEFFERSON AVE
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-7101
Mailing Address - Country:US
Mailing Address - Phone:419-251-1963
Mailing Address - Fax:419-872-9549
Practice Address - Street 1:1103 VILLAGE SQUARE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-1783
Practice Address - Country:US
Practice Address - Phone:419-872-3213
Practice Address - Fax:419-872-9549
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35092177207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2943659Medicaid
MI4499916Medicaid
OH2943659Medicaid
OHH83017Medicare UPIN