Healthcare Provider Details

I. General information

NPI: 1326286279
Provider Name (Legal Business Name): MALCOLM O PERRY III MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2009
Last Update Date: 02/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 RAINTREE CIR SUITE 240
ALLEN TX
75013-4901
US

IV. Provider business mailing address

1111 RAINTREE CIR SUITE 240
ALLEN TX
75013-4901
US

V. Phone/Fax

Practice location:
  • Phone: 469-854-6116
  • Fax:
Mailing address:
  • Phone: 469-854-6116
  • Fax: 469-854-6399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberJ1476
License Number StateTX

VIII. Authorized Official

Name: MALCOLM O PERRY III
Title or Position: PRESIDENT
Credential: MD
Phone: 469-854-6116