Healthcare Provider Details

I. General information

NPI: 1093883795
Provider Name (Legal Business Name): THOMAS J PUTNAM M. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: T. JOSEPH PUTNAM M. D.

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 11/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HOSPITAL ST STE 200
BOONEVILLE MS
38829-3354
US

IV. Provider business mailing address

PO BOX 788
BOONEVILLE MS
38829-0788
US

V. Phone/Fax

Practice location:
  • Phone: 662-720-3000
  • Fax: 662-720-3069
Mailing address:
  • Phone: 662-720-3000
  • Fax: 662-720-3069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number09729
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: