Provider Demographics
NPI:1629285358
Name:PURI, RAJEEV (MD)
Entity Type:Individual
Prefix:
First Name:RAJEEV
Middle Name:
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 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 W COCOA BEACH CSWY
Practice Address - Street 2:
Practice Address - City:COCOA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32931-5595
Practice Address - Country:US
Practice Address - Phone:321-434-8777
Practice Address - Fax:321-434-1775
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD19998208600000X
FLME154811208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL113854400Medicaid
FLO5879OtherFL HF MA