Provider Demographics
NPI:1356409957
Name:PURO, EDWARD ALLAN (MD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:ALLAN
Last Name:PURO
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 1:1315 AUBERT AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63113-1918
Mailing Address - Country:US
Mailing Address - Phone:314-449-9726
Mailing Address - Fax:314-838-0234
Practice Address - Street 1:1315 AUBERT AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63113-1918
Practice Address - Country:US
Practice Address - Phone:314-449-9726
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR7135207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO201874203Medicaid
1309Medicare ID - Type Unspecified
MO000001309Medicare PIN
MO201874203Medicaid