Provider Demographics
NPI:1902819469
Name:PURNELL, WILLIAM EBBERT JR (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:EBBERT
Last Name:PURNELL
Suffix:JR
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 1:4744 INDEPENDENCE DR SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-6407
Mailing Address - Country:US
Mailing Address - Phone:503-363-0060
Mailing Address - Fax:
Practice Address - Street 1:1155 MISSION ST SE
Practice Address - Street 2:SUITE 105
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-6228
Practice Address - Country:US
Practice Address - Phone:503-362-0254
Practice Address - Fax:503-362-1082
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD146912085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORE30385Medicare UPIN
ORR120581Medicare PIN
OR120581Medicare ID - Type UnspecifiedWVR