Healthcare Provider Details

I. General information

NPI: 1518278340
Provider Name (Legal Business Name): GAVIN PUTHOFF M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2010
Last Update Date: 09/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 S NEW BALLAS RD SUITE 1015B
SAINT LOUIS MO
63141-8232
US

IV. Provider business mailing address

621 S NEW BALLAS RD SUITE 1015B
SAINT LOUIS MO
63141-8232
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-8965
  • Fax: 314-251-8966
Mailing address:
  • Phone: 314-251-8965
  • Fax: 314-251-8966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number27763
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2013039277
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: