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NPI Code Detail

MEDICARE: JACK PURDY MD INC

MEDICARE: JACK PURDY MD INC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207X00000XOrthopaedic Surgery PhysicianG31387CA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1G31387OTHERCASTATE LICENSE

General Provider Information

NPI Number : 1154510899
Entity Type Code : Organization
Provider Name (Legal Business Name) : JACK PURDY MD INC
Provider Business Mailing Address
First Line : 17525 VENTURA BLVD STE 203
Second Line :
City : ENCINO
State : CA
Zip : 91316-5109
Country : US
Telephone Number : 818-986-0200
Fax Number : 818-986-4393
Provider Business Practice Location Address
First Line : 17525 VENTURA BLVD STE 203
Second Line :
City : ENCINO
State : CA
Zip : 91316-5109
Country : US
Telephone Number : 818-986-0200
Fax Number : 818-986-4393
Authorized Official
Title or Position : OWNER/ CEO PHYSCIAN AND SURGEON
Name : JACK C PURDY
Credential : M.D.
Telephone Number : 310-453-3533
Provider Enumeration Date : 10/18/2007
Last Update Date : 02/26/2010

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