Healthcare Provider Details

I. General information

NPI: 1326028309
Provider Name (Legal Business Name): DIVYESH PUROHIT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 05/12/2022
Certification Date: 05/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

557 W BROADWAY
SHELBURN IN
47879
US

IV. Provider business mailing address

3991 GOLF BAG LN
TERRE HAUTE IN
47802-8145
US

V. Phone/Fax

Practice location:
  • Phone: 812-234-6053
  • Fax: 812-478-3416
Mailing address:
  • Phone: 812-299-3261
  • Fax: 812-316-5151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01045492A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number01045492A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: