Healthcare Provider Details

I. General information

NPI: 1225051774
Provider Name (Legal Business Name): BRADLEY SCOTT PUTTY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 01/11/2023
Certification Date: 01/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1008 S SPRING AVE
SAINT LOUIS MO
63110-2520
US

IV. Provider business mailing address

2215 TURKEY RUN LN
SPRINGFIELD MO
65809-3554
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-4717
  • Fax: 314-977-1877
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberQ1000
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: