Healthcare Provider Details

I. General information

NPI: 1083931067
Provider Name (Legal Business Name): VICENTE JOSE UNDURRAGA PERL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2010
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W BROADWAY ST FL 4
MISSOULA MT
59802-4008
US

IV. Provider business mailing address

PO BOX 31001-4110
PASADENA CA
91110-4110
US

V. Phone/Fax

Practice location:
  • Phone: 406-329-5828
  • Fax: 406-329-5864
Mailing address:
  • Phone: 406-329-5828
  • Fax: 406-329-5864

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberM-14232
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberMED-PHYS-LIC-113704
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: