Provider Demographics
NPI:1679593420
Name:PERDUE, KEVIN DALE (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:DALE
Last Name:PERDUE
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 1:1901 REDROCK DR
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-5683
Mailing Address - Country:US
Mailing Address - Phone:505-863-7000
Mailing Address - Fax:505-726-6720
Practice Address - Street 1:1900 REDROCK DR
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5682
Practice Address - Country:US
Practice Address - Phone:505-863-7200
Practice Address - Fax:505-726-6720
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2006-0520207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ124003Medicaid
NM56238835Medicaid
NMNM001H96OtherBCBS
NMQMYPR0072225OtherMOLINA
NM10027150OtherLOVELACE
NM56238835Medicaid