Healthcare Provider Details

I. General information

NPI: 1164420477
Provider Name (Legal Business Name): JAMIE L. PUCKETT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2005
Last Update Date: 09/03/2024
Certification Date: 09/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 HIGHWAY K
O FALLON MO
63366-8431
US

IV. Provider business mailing address

PO BOX 955534 SUITE 100
SAINT LOUIS MO
63195-0001
US

V. Phone/Fax

Practice location:
  • Phone: 636-379-6363
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number108740
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: