Provider Demographics
NPI:1528065695
Name:WALL, MARYANN PURDY (MD)
Entity type:Individual
Prefix:
First Name:MARYANN
Middle Name:PURDY
Last Name:WALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:940 CENTRAL PARK DR
Mailing Address - Street 2:SUITE 207
Mailing Address - City:STEAMBOAT SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80487-8816
Mailing Address - Country:US
Mailing Address - Phone:970-879-3200
Mailing Address - Fax:970-879-4608
Practice Address - Street 1:940 CENTRAL PARK DR
Practice Address - Street 2:SUITE 207
Practice Address - City:STEAMBOAT SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80487-8816
Practice Address - Country:US
Practice Address - Phone:970-879-3200
Practice Address - Fax:970-879-4608
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO37010207Y00000X, 2082S0099X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Not Answered2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01370105Medicaid
CO93381Medicare ID - Type Unspecified
CO01370105Medicaid