Provider Demographics
NPI:1649519646
Name:KENNETH R PURDOM II MD INC
Entity type:Organization
Organization Name:KENNETH R PURDOM II MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:R
Authorized Official - Last Name:PURDOM
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:562-698-0948
Mailing Address - Street 1:6354 PAINTER AVE
Mailing Address - Street 2:
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90601-4632
Mailing Address - Country:US
Mailing Address - Phone:562-698-0948
Mailing Address - Fax:562-698-7058
Practice Address - Street 1:6354 PAINTER AVE
Practice Address - Street 2:
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90601-4632
Practice Address - Country:US
Practice Address - Phone:562-698-0948
Practice Address - Fax:562-698-7058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-11
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA21180174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGZ729AMedicare PIN
CAA82374Medicare UPIN