Provider Demographics
NPI:1811945140
Name:IYENGAR, PURUSHOTHAMA (MD)
Entity type:Individual
Prefix:DR
First Name:PURUSHOTHAMA
Middle Name:
Last Name:IYENGAR
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 1:100 NEW SALEM RD
Mailing Address - Street 2:SUITE 116
Mailing Address - City:UNIONTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15401-8936
Mailing Address - Country:US
Mailing Address - Phone:724-437-0729
Mailing Address - Fax:724-437-2761
Practice Address - Street 1:1051 MORRELL AVE
Practice Address - Street 2:
Practice Address - City:CONNELLSVILLE
Practice Address - State:PA
Practice Address - Zip Code:15425-3958
Practice Address - Country:US
Practice Address - Phone:724-437-0729
Practice Address - Fax:724-437-2761
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-042463-L2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
618489OtherHIGHMARK
PA0012961880007Medicaid
329-573-0OtherECFMG
322242OtherMHNET
PA0012961880007Medicaid
PA618489EPMMedicare PIN