Provider Demographics
NPI:1144354788
Name:PURISIMA, CLEMENTINO (MD)
Entity type:Individual
Prefix:
First Name:CLEMENTINO
Middle Name:
Last Name:PURISIMA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 GRISTMILL LN
Mailing Address - Street 2:
Mailing Address - City:UPPER SADDLE RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:07458-1316
Mailing Address - Country:US
Mailing Address - Phone:201-863-5065
Mailing Address - Fax:201-934-1383
Practice Address - Street 1:1005 NEW YORK AVE
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:NJ
Practice Address - Zip Code:07087-4127
Practice Address - Country:US
Practice Address - Phone:201-863-5065
Practice Address - Fax:201-934-1383
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA03503500208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice