Basic Information
| Provider Information | |||||||||
| NPI: | 1992777338 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LALL | ||||||||
| FirstName: | PURANDATH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 417 | ||||||||
| Address2: | |||||||||
| City: | STUART | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349950417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7722232832 | ||||||||
| FaxNumber: | 7722235646 | ||||||||
| Practice Location | |||||||||
| Address1: | 10080 SW INNOVATION WAY STE 201 | ||||||||
| Address2: | |||||||||
| City: | PORT ST LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349872129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7723443811 | ||||||||
| FaxNumber: | 7723443890 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2006 | ||||||||
| LastUpdateDate: | 10/14/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | 47964 | MN | N | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 2086S0129X | 125959 | FL | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 020817900 | 05 | FL | MEDICAID | 182855000 | 05 | MN | MEDICAID | W81GM | 01 | FL | FLORIDA BLUE | OTHER |