Healthcare Provider Details

I. General information

NPI: 1619953072
Provider Name (Legal Business Name): PURUSHOTTAM V PANDE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 07/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 BROAD AVE SUITE 270
GULFPORT MS
39501-2404
US

IV. Provider business mailing address

PO BOX 1810
GULFPORT MS
39502-1810
US

V. Phone/Fax

Practice location:
  • Phone: 228-575-1234
  • Fax: 228-575-1240
Mailing address:
  • Phone: 228-575-1234
  • Fax: 228-575-1240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number11683
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: