Provider Demographics
NPI:1295745933
Name:SHAWN PURIFOY, M.D., P.A.
Entity type:Organization
Organization Name:SHAWN PURIFOY, M.D., P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:PURIFOY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-337-1836
Mailing Address - Street 1:850 HENRY ST
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:AR
Mailing Address - Zip Code:72104-2712
Mailing Address - Country:US
Mailing Address - Phone:501-337-1836
Mailing Address - Fax:501-337-7935
Practice Address - Street 1:850 HENRY ST
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:AR
Practice Address - Zip Code:72104-2712
Practice Address - Country:US
Practice Address - Phone:501-337-1836
Practice Address - Fax:501-337-7935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE0603207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR160100002Medicaid
ARG12502Medicare UPIN
AR160100002Medicaid