Provider Demographics
NPI:1053399204
Name:PURYEAR, DOUGLAS A (MD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:A
Last Name:PURYEAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 E ALAMEDA ST
Mailing Address - Street 2:APT 507
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-2186
Mailing Address - Country:US
Mailing Address - Phone:505-982-9337
Mailing Address - Fax:
Practice Address - Street 1:4 CAMINO DE VECINOS
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-7901
Practice Address - Country:US
Practice Address - Phone:505-982-9337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-07
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM90-962084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM30816Medicaid
NM100647OtherVALUE OPTIONS
NM30816Medicaid