Healthcare Provider Details

I. General information

NPI: 1720036072
Provider Name (Legal Business Name): LINDALL A PERRY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 09/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 KEENE ST
COLUMBIA MO
65201-6625
US

IV. Provider business mailing address

401 KEENE ST
COLUMBIA MO
65201-6625
US

V. Phone/Fax

Practice location:
  • Phone: 573-876-1616
  • Fax: 573-876-1678
Mailing address:
  • Phone: 573-876-1616
  • Fax: 573-876-1678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number107883
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number107883
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: