MEDICARE: TEDD R PUCKETT MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	0101058838	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	0193226	OTHER	VA	GIGNA
3	258585	OTHER	VT	ANTHEM (BLUE CROSS)
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	5978709	OTHER	VA	AETNA
6	0800644	OTHER	VA	UNITED HEALTHCARE
7	452768	OTHER	VA	ANTHEM (BLUE CROSS)

General Provider Information

NPI Number	:	1215007315
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TEDD R PUCKETT MD

Provider Business Mailing Address
First Line	:	106 S FRANKLIN ST STE C
Second Line	:
City	:	CHRISTIANSBURG
State	:	VA
Zip	:	24073-3547
Country	:	US
Telephone Number	:	540-381-2013
Fax Number	:

Provider Business Practice Location Address
First Line	:	106 S FRANKLIN ST STE C
Second Line	:
City	:	CHRISTIANSBURG
State	:	VA
Zip	:	24073-3547
Country	:	US
Telephone Number	:	540-381-2013
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/08/2006
Last Update Date	:	04/29/2015

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