Healthcare Provider Details

I. General information

NPI: 1124267778
Provider Name (Legal Business Name): BENJAMIN N PUCKETT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2009
Last Update Date: 12/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1240 JESSE JEWELL PKWY STE 300
GAINESVILLE GA
30501
US

IV. Provider business mailing address

1240 JESSE JEWELL PKWY STE 300
GAINESVILLE GA
30501
US

V. Phone/Fax

Practice location:
  • Phone: 770-532-7202
  • Fax: 678-450-3778
Mailing address:
  • Phone: 770-532-7202
  • Fax: 678-450-3778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number057911
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: