Healthcare Provider Details

I. General information

NPI: 1932153640
Provider Name (Legal Business Name): MICHAEL JOHN PUK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 02/04/2022
Certification Date: 02/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 E SAN MARNAN DRIVE
WATERLOO IA
50702-5611
US

IV. Provider business mailing address

PO BOX 2758
WATERLOO IA
50704-2758
US

V. Phone/Fax

Practice location:
  • Phone: 319-234-2616
  • Fax: 319-234-1939
Mailing address:
  • Phone: 319-234-2616
  • Fax: 319-234-1939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number29301
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: