Healthcare Provider Details

I. General information

NPI: 1679593420
Provider Name (Legal Business Name): KEVIN DALE PERDUE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 REDROCK DR
GALLUP NM
87301-5682
US

IV. Provider business mailing address

1901 REDROCK DR
GALLUP NM
87301-5683
US

V. Phone/Fax

Practice location:
  • Phone: 505-863-7200
  • Fax: 505-726-6720
Mailing address:
  • Phone: 505-863-7000
  • Fax: 505-726-6720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD2006-0520
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: