Provider Demographics
NPI:1154510899
Name:JACK PURDY MD INC
Entity type:Organization
Organization Name:JACK PURDY MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ CEO PHYSCIAN AND SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:C
Authorized Official - Last Name:PURDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-453-3533
Mailing Address - Street 1:17525 VENTURA BLVD STE 203
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-5109
Mailing Address - Country:US
Mailing Address - Phone:818-986-0200
Mailing Address - Fax:818-986-4393
Practice Address - Street 1:17525 VENTURA BLVD STE 203
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-5109
Practice Address - Country:US
Practice Address - Phone:818-986-0200
Practice Address - Fax:818-986-4393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-18
Last Update Date:2010-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG31387207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG31387OtherSTATE LICENSE
A44751Medicare UPIN