Provider Demographics
NPI:1053612440
Name:PURI, KAUTILYA (MD)
Entity type:Individual
Prefix:
First Name:KAUTILYA
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 1:1762 CENTRAL AVE
Mailing Address - Street 2:2 FLOOR, SUITE # 202
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205-4773
Mailing Address - Country:US
Mailing Address - Phone:518-389-1310
Mailing Address - Fax:518-464-8918
Practice Address - Street 1:1762 CENTRAL AVE
Practice Address - Street 2:2 FLOOR, SUITE # 202
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-4773
Practice Address - Country:US
Practice Address - Phone:518-389-1310
Practice Address - Fax:518-464-8918
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-16
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY217675207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine