Healthcare Provider Details

I. General information

NPI: 1063584092
Provider Name (Legal Business Name): MICHELLE ANN PUTNAM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 03/06/2020
Certification Date: 03/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3831 HUGHES AVE SUITE 504
CULVER CITY CA
90232-2751
US

IV. Provider business mailing address

3831 HUGHES AVE STE 704
CULVER CITY CA
90232-6839
US

V. Phone/Fax

Practice location:
  • Phone: 310-204-4111
  • Fax: 310-204-4474
Mailing address:
  • Phone: 310-204-4111
  • Fax: 310-204-4474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License NumberA83674
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207YX0602X
TaxonomyOtolaryngic Allergy Physician
License NumberA83674
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberA83674
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: