MEDICARE: LAURA 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	390200000X	Student in an Organized Health Care Education/Training Program
2	207V00000X	Obstetrics & Gynecology Physician	ME150404	FL

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

General Provider Information

NPI Number	:	1558894683
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA PUCKETT MD

Provider Business Mailing Address
First Line	:	5525 N STANTON ST APT 29G
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79912-6408
Country	:	US
Telephone Number	:	281-682-1363
Fax Number	:

Provider Business Practice Location Address
First Line	:	3000 NE 2ND AVE APT 617
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33137-5406
Country	:	US
Telephone Number	:	281-682-1363
Fax Number	:

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

Provider Enumeration Date	:	04/05/2017
Last Update Date	:	07/26/2021

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