Provider Demographics
NPI:1609885177
Name:VERMA, PURUSHOTTAM LAL (MD)
Entity Type:Individual
Prefix:DR
First Name:PURUSHOTTAM
Middle Name:LAL
Last Name:VERMA
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 1:830 PENNSYLVANIA AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25302-3302
Mailing Address - Country:US
Mailing Address - Phone:304-345-1644
Mailing Address - Fax:304-345-1578
Practice Address - Street 1:830 PENNSYLVANIA AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25302-3302
Practice Address - Country:US
Practice Address - Phone:304-345-1644
Practice Address - Fax:304-345-1578
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV09324208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0111969000Medicaid
WV0111969000Medicaid