Basic Information
Provider Information | |||||||||
NPI: | 1720214489 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PURDOM | ||||||||
FirstName: | VIRGINIA | ||||||||
MiddleName: | KING | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PURDOM | ||||||||
OtherFirstName: | VIRGINIA | ||||||||
OtherMiddleName: | KING | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 109 DANIEL DR | ||||||||
Address2: |   | ||||||||
City: | DANVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 404222527 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8592363361 | ||||||||
FaxNumber: | 8592399484 | ||||||||
Practice Location | |||||||||
Address1: | 109 DANIEL DR | ||||||||
Address2: |   | ||||||||
City: | DANVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 404222527 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8592363361 | ||||||||
FaxNumber: | 8592399484 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/08/2009 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 31728 | SC | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 45084 | KY | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 7100202750 | 05 | KY |   | MEDICAID |