Provider Demographics
NPI:1558356188
Name:PURI, RAJINDER S (MD)
Entity Type:Individual
Prefix:DR
First Name:RAJINDER
Middle Name:S
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 1:4120 US HIGHWAY 98 N STE 400
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33809-3882
Mailing Address - Country:US
Mailing Address - Phone:863-858-7878
Mailing Address - Fax:863-853-7808
Practice Address - Street 1:4120 US HIGHWAY 98 N STE 400
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33809-3882
Practice Address - Country:US
Practice Address - Phone:863-858-7878
Practice Address - Fax:863-853-7808
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-20
Last Update Date:2010-06-29
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-04-04
Provider Licenses
StateLicense IDTaxonomies
FLME28211207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL058621800Medicaid
FL058621800Medicaid
FLD58547Medicare UPIN