Healthcare Provider Details

I. General information

NPI: 1730539685
Provider Name (Legal Business Name): ROBERT ANTHONY PUCKETT D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2016
Last Update Date: 09/08/2025
Certification Date: 09/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1069 DELAWARE AVE STE 101A
MARION OH
43302-6459
US

IV. Provider business mailing address

1069 DELAWARE AVE STE 101A
MARION OH
43302-6459
US

V. Phone/Fax

Practice location:
  • Phone: 419-294-5758
  • Fax: 419-294-5358
Mailing address:
  • Phone: 419-294-5758
  • Fax: 419-294-5358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34.013890
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOT016962
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: