Provider Demographics
NPI:1679535827
Name:PURDY, MALCOLM H (MD)
Entity Type:Individual
Prefix:DR
First Name:MALCOLM
Middle Name:H
Last Name:PURDY
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 1:715 DR MARTIN LUTHER KING JR AVE NE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-3661
Mailing Address - Country:US
Mailing Address - Phone:505-727-3040
Mailing Address - Fax:505-727-3099
Practice Address - Street 1:715 DR MARTIN LUTHER KING JR AVE SE
Practice Address - Street 2:SUITE 102
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102
Practice Address - Country:US
Practice Address - Phone:505-727-3040
Practice Address - Fax:505-727-3099
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM95-325174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMT5579Medicaid
F45629Medicare UPIN