Healthcare Provider Details

I. General information

NPI: 1457315566
Provider Name (Legal Business Name): MARK LEE PURNELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 03/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 E VALLEY RD
BASALT CO
81621-8304
US

IV. Provider business mailing address

1450 E VALLEY RD
BASALT CO
81621-8304
US

V. Phone/Fax

Practice location:
  • Phone: 970-927-8611
  • Fax: 970-927-8633
Mailing address:
  • Phone: 970-927-8611
  • Fax: 970-927-8633

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number26418
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1264183
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: