Provider Demographics
NPI:1922111541
Name:PERRY, MALCOLM O III (MD)
Entity Type:Individual
Prefix:
First Name:MALCOLM
Middle Name:O
Last Name:PERRY
Suffix:III
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 1:950 W BETHANY DR STE 360
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-3837
Mailing Address - Country:US
Mailing Address - Phone:469-854-6116
Mailing Address - Fax:
Practice Address - Street 1:950 W BETHANY DR STE 360
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-3837
Practice Address - Country:US
Practice Address - Phone:469-854-6116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ1476208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX035007601Medicaid
F57444Medicare UPIN
TX035007601Medicaid