Healthcare Provider Details

I. General information

NPI: 1508835661
Provider Name (Legal Business Name): ROBERT J PUCKETT JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 04/29/2020
Certification Date: 04/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5470 MARTHA BERRY HWY
ARMUCHEE GA
30105-2302
US

IV. Provider business mailing address

221 TECHNOLOGY PKWY NW
ROME GA
30165-1369
US

V. Phone/Fax

Practice location:
  • Phone: 706-235-1156
  • Fax:
Mailing address:
  • Phone: 762-235-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number050423
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: