Healthcare Provider Details

I. General information

NPI: 1356330187
Provider Name (Legal Business Name): PURNIMA VYAVAHARKAR PEDIATRIC PRACTICE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8400 OSWEGO RD
LIVERPOOL NY
13090-1004
US

IV. Provider business mailing address

PO BOX 2001
EAST SYRACUSE NY
13057-4501
US

V. Phone/Fax

Practice location:
  • Phone: 315-652-7939
  • Fax: 315-652-6331
Mailing address:
  • Phone: 315-449-2208
  • Fax: 315-362-5120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: PURNIMA VYAVAHARKAR
Title or Position: OWNER
Credential: MD
Phone: 315-652-7939