Provider Demographics
NPI:1386800852
Name:PURI, RUCHIR (MD)
Entity type:Individual
Prefix:DR
First Name:RUCHIR
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 1:1900 TEBEAU ST
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-6357
Mailing Address - Country:US
Mailing Address - Phone:912-338-6010
Mailing Address - Fax:
Practice Address - Street 1:1908 ALICE STREET
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501
Practice Address - Country:US
Practice Address - Phone:912-338-6010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-04
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA071973208600000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHJ815ZMedicare PIN