Healthcare Provider Details

I. General information

NPI: 1457648842
Provider Name (Legal Business Name): ANDREW DAVID PUCKER OD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2011
Last Update Date: 08/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1716 UNIVERSITY BLVD HPB G080A
BIRMINGHAM AL
35294-0010
US

IV. Provider business mailing address

1716 UNIVERSITY BLVD HPB G080A
BIRMINGHAM AL
35294-0010
US

V. Phone/Fax

Practice location:
  • Phone: 205-975-2020
  • Fax: 205-934-6755
Mailing address:
  • Phone: 205-975-2020
  • Fax: 205-934-6755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number6064
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT2979
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberT-228-TA-A55
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: