Provider Demographics
NPI:1023097839
Name:PURI, SANJEEV (MD)
Entity type:Individual
Prefix:DR
First Name:SANJEEV
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 1:1236 E RUSHOLME ST STE 300
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52803-2473
Mailing Address - Country:US
Mailing Address - Phone:563-324-2992
Mailing Address - Fax:563-324-8562
Practice Address - Street 1:1100 36TH AVENUE
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265
Practice Address - Country:US
Practice Address - Phone:309-743-6700
Practice Address - Fax:309-743-6709
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036107895207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA3561308Medicaid
P00208166OtherMEDICARE RAILROAD
G87443Medicare UPIN
IAI14076Medicare PIN
IA3561308Medicaid