Healthcare Provider Details

I. General information

NPI: 1346647435
Provider Name (Legal Business Name): PUTNAM NEUROLOGY GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2014
Last Update Date: 12/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 ZEAGLER DR SUITE #230
PALATKA FL
32177-3883
US

IV. Provider business mailing address

800 ZEAGLER DR SUITE #230
PALATKA FL
32177-3883
US

V. Phone/Fax

Practice location:
  • Phone: 386-385-3043
  • Fax: 386-385-3187
Mailing address:
  • Phone: 386-385-3043
  • Fax: 386-385-3187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME108923
License Number StateFL

VIII. Authorized Official

Name: DR. FAWZI YOUSEF ELSAGGA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 386-385-3043