Provider Demographics
NPI:1073647442
Name:PERDUE, STEPHANIE WILKS (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:WILKS
Last Name:PERDUE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:9811 MALLARD DR
Mailing Address - Street 2:SUITE 109
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20708-3143
Mailing Address - Country:US
Mailing Address - Phone:301-776-8000
Mailing Address - Fax:301-776-6753
Practice Address - Street 1:9811 MALLARD DR
Practice Address - Street 2:SUITE 109
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20708-3143
Practice Address - Country:US
Practice Address - Phone:301-776-8000
Practice Address - Fax:301-776-6753
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00735612080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD063563400Medicaid