Healthcare Provider Details

I. General information

NPI: 1205044146
Provider Name (Legal Business Name): JUSTIN DAVID PUCKETT DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 09/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2004 N BALTIMORE ST STE A
KIRKSVILLE MO
63501-5107
US

IV. Provider business mailing address

PO BOX 551
HANNIBAL MO
63401-0551
US

V. Phone/Fax

Practice location:
  • Phone: 660-665-7575
  • Fax: 660-665-7576
Mailing address:
  • Phone: 660-665-7575
  • Fax: 660-665-7576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2006017939
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2007018127
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: