Provider Demographics
NPI:1770558652
Name:PURCELL, JOHN MICHAEL SR (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MICHAEL
Last Name:PURCELL
Suffix:SR
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 1:818 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203
Mailing Address - Country:US
Mailing Address - Phone:518-482-1515
Mailing Address - Fax:
Practice Address - Street 1:1520 ROUTE 9
Practice Address - Street 2:
Practice Address - City:CLIFTON PARK
Practice Address - State:NY
Practice Address - Zip Code:12065-5669
Practice Address - Country:US
Practice Address - Phone:518-482-1515
Practice Address - Fax:518-383-3376
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-22
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY099499207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D75380Medicare UPIN
30386BMedicare ID - Type Unspecified