Provider Demographics
NPI:1578549085
Name:GARG, PURUSHOTTAM K (MD)
Entity Type:Individual
Prefix:
First Name:PURUSHOTTAM
Middle Name:K
Last Name:GARG
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:PO BOX 2276
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32513-2276
Mailing Address - Country:US
Mailing Address - Phone:850-995-8811
Mailing Address - Fax:850-995-8810
Practice Address - Street 1:5553 HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:PACE
Practice Address - State:FL
Practice Address - Zip Code:32571-1540
Practice Address - Country:US
Practice Address - Phone:850-995-8811
Practice Address - Fax:850-995-8810
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2012-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME68880207Q00000X
ALMD.30109207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
080125539OtherMEDICARE RAILROAD
AL591-58026OtherBLUE CROSS BLUE SHIELD
AL591-95710OtherBLUE CROSS BLUE SHIELD
AL591-58027OtherBLUE CROSS BLUE SHIELD
FL37816820Medicaid
FL27429OtherBLUE CROSS BLUE SHIELD
FL27429Medicare PIN
FL27429XMedicare PIN
F89226Medicare UPIN