MEDICARE: DR. STEPHEN L. PUTTHOFF D.O.

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	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	H2164	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CLO426	OTHER		BLUE CROSS AND BLUE SHIEL

General Provider Information

NPI Number	:	1366411431
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STEPHEN L. PUTTHOFF D.O.

Provider Business Mailing Address
First Line	:	3500 CAMP BOWIE BLVD
Second Line	:	UNTHSC DEPT. OF QUALITY MANAGEMENT. EAD 324
City	:	FORT WORTH
State	:	TX
Zip	:	76107
Country	:	US
Telephone Number	:	817-735-0111
Fax Number	:

Provider Business Practice Location Address
First Line	:	3500 CAMP BOWIE BLVD
Second Line	:	EAD 318
City	:	FORT WORTH
State	:	TX
Zip	:	76107-2644
Country	:	US
Telephone Number	:	817-735-2429
Fax Number	:

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

Provider Enumeration Date	:	03/14/2006
Last Update Date	:	07/09/2007

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