Healthcare Provider Details

I. General information

NPI: 1043717838
Provider Name (Legal Business Name): RAVI VISHRAM PURUSHUTTAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2018
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6387 RAMSEY ST UNIT 210
FAYETTEVILLE NC
28311-9442
US

IV. Provider business mailing address

135 N.UNION ST.
OLEAN NY
14760
US

V. Phone/Fax

Practice location:
  • Phone: 910-615-3920
  • Fax: 910-321-6221
Mailing address:
  • Phone: 716-375-7500
  • Fax: 716-701-6854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number311963
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: