Healthcare Provider Details

I. General information

NPI: 1871569111
Provider Name (Legal Business Name): JOHN LESLIE PUTNAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 11/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4350 S NATIONAL AVE SUITE C200
SPRINGFIELD MO
65810-2607
US

IV. Provider business mailing address

4350 S NATIONAL AVE SUITE C200
SPRINGFIELD MO
65810-2607
US

V. Phone/Fax

Practice location:
  • Phone: 417-447-1000
  • Fax: 417-447-6150
Mailing address:
  • Phone: 417-447-1000
  • Fax: 417-447-6150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberR6H15
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: