Provider Demographics
NPI:1457508343
Name:VINAYAK V PURANDARE MD PL
Entity Type:Organization
Organization Name:VINAYAK V PURANDARE MD PL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VINAYAK
Authorized Official - Middle Name:V
Authorized Official - Last Name:PURANDARE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-672-8595
Mailing Address - Street 1:305 MEMORIAL MEDICAL PARKWAY, SUITE 507
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117
Mailing Address - Country:US
Mailing Address - Phone:386-672-8595
Mailing Address - Fax:386-677-4987
Practice Address - Street 1:401 LAKEBRIDGE PLAZA DR
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5157
Practice Address - Country:US
Practice Address - Phone:386-672-8595
Practice Address - Fax:386-677-4987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-21
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0045136207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL048136000Medicaid
FL048136000Medicaid