Healthcare Provider Details

I. General information

NPI: 1578549085
Provider Name (Legal Business Name): PURUSHOTTAM K. GARG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 08/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5553 HIGHWAY 90
PACE FL
32571-1540
US

IV. Provider business mailing address

PO BOX 2276
PENSACOLA FL
32513-2276
US

V. Phone/Fax

Practice location:
  • Phone: 850-995-8811
  • Fax: 850-995-8810
Mailing address:
  • Phone: 850-995-8811
  • Fax: 850-995-8810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME68880
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD.30109
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: