Healthcare Provider Details

I. General information

NPI: 1790125136
Provider Name (Legal Business Name): DARRYL PUTZER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2013
Last Update Date: 06/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 N 4TH ST
SPRINGFIELD IL
62702-5238
US

IV. Provider business mailing address

PO BOX 19670
SPRINGFIELD IL
62794-9670
US

V. Phone/Fax

Practice location:
  • Phone: 217-757-8100
  • Fax: 217-757-8161
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125063962
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: