Provider Demographics
NPI:1962672337
Name:KAPIL PURI MD P A
Entity Type:Organization
Organization Name:KAPIL PURI MD P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KAPIL
Authorized Official - Middle Name:
Authorized Official - Last Name:PURI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-279-4600
Mailing Address - Street 1:PO BOX 524
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32588-0524
Mailing Address - Country:US
Mailing Address - Phone:850-279-4500
Mailing Address - Fax:850-279-4566
Practice Address - Street 1:1001 COLLEGE BLVD W
Practice Address - Street 2:STE H
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-1099
Practice Address - Country:US
Practice Address - Phone:850-279-4600
Practice Address - Fax:850-279-4566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-02
Last Update Date:2008-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME91106208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270922800Medicaid
FLAK816OtherMEDICARE ID-TYPE UNSPECIFIED
FLI19133Medicare UPIN