Provider Demographics
NPI:1497789507
Name:JOHN, JOHN PUTHENPURACKAL (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:PUTHENPURACKAL
Last Name:JOHN
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 1:514 W 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:PA
Mailing Address - Zip Code:16365-2201
Mailing Address - Country:US
Mailing Address - Phone:814-723-5545
Mailing Address - Fax:814-723-6355
Practice Address - Street 1:514 W 3RD AVE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:PA
Practice Address - Zip Code:16365-2201
Practice Address - Country:US
Practice Address - Phone:814-723-5545
Practice Address - Fax:814-723-6355
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD051025L2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAF69671Medicare UPIN
PA444470Medicare ID - Type Unspecified