Healthcare Provider Details

I. General information

NPI: 1154173292
Provider Name (Legal Business Name): COLTON WADE PUTNAM DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2024
Last Update Date: 06/26/2024
Certification Date: 06/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 E. CHEVES STREET
FLORENCE SC
29506
US

IV. Provider business mailing address

555 E. CHEVES STREET
FLORENCE SC
29506
US

V. Phone/Fax

Practice location:
  • Phone: 843-777-2800
  • Fax:
Mailing address:
  • Phone: 843-777-2800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberLL92459
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: