Healthcare Provider Details

I. General information

NPI: 1336438449
Provider Name (Legal Business Name): SOPHIA PUREKAL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2011
Last Update Date: 10/05/2022
Certification Date: 10/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5200 EASTERN AVE
BALTIMORE MD
21224-2734
US

IV. Provider business mailing address

6201 GREENLEIGH AVE
MIDDLE RIVER MD
21220-2004
US

V. Phone/Fax

Practice location:
  • Phone: 410-550-2999
  • Fax:
Mailing address:
  • Phone:
  • Fax: 410-735-5218

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD0078346
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: