Provider Demographics
NPI:1760596514
Name:PURICELLI, MARK S (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:PURICELLI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1475
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50306-1475
Mailing Address - Country:US
Mailing Address - Phone:515-358-0011
Mailing Address - Fax:515-358-0099
Practice Address - Street 1:1111 6TH AVE
Practice Address - Street 2:EAST TOWER SUITE A100
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50314-2610
Practice Address - Country:US
Practice Address - Phone:515-358-0011
Practice Address - Fax:515-358-0099
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA032242084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2187229Medicaid
IA13404Medicare ID - Type Unspecified
IAF58064Medicare UPIN