Provider Demographics
NPI:1720036072
Name:PERRY, LINDALL A (MD)
Entity Type:Individual
Prefix:
First Name:LINDALL
Middle Name:A
Last Name:PERRY
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 1:401 KEENE ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-6625
Mailing Address - Country:US
Mailing Address - Phone:573-876-1616
Mailing Address - Fax:573-876-1678
Practice Address - Street 1:401 KEENE ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-6625
Practice Address - Country:US
Practice Address - Phone:573-876-1616
Practice Address - Fax:573-876-1678
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO107883207N00000X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208550749Medicaid
94758Medicare ID - Type Unspecified
G35031Medicare UPIN