Healthcare Provider Details

I. General information

NPI: 1861754269
Provider Name (Legal Business Name): ROBERT PUTKO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2012
Last Update Date: 01/05/2025
Certification Date: 01/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34800 BOB WILSON DR
SAN DIEGO CA
92134-1098
US

IV. Provider business mailing address

34800 BOB WILSON DR
SAN DIEGO CA
92134-1098
US

V. Phone/Fax

Practice location:
  • Phone: 301-295-4462
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number0101254517
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: