Healthcare Provider Details

I. General information

NPI: 1194389312
Provider Name (Legal Business Name): ROY PUTNAM JR. D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2019
Last Update Date: 08/28/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 JOHN ST STE M-510
KALAMAZOO MI
49007-5341
US

IV. Provider business mailing address

601 JOHN STREET BOX 42
KALAMAZOO MI
49007
US

V. Phone/Fax

Practice location:
  • Phone: 269-341-7762
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number5101028260
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: