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General NPI Number Information
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NPI Number | 1023066404
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Entity Type | Individual
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Provider Name | SAMUEL GRADY PUTNAM MD
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Gender | Male
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Dates
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Enumeration Date | 05/05/2006
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Last Update Date | 05/06/2025
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Provider Practice Location Address
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Address Line | 55 PHYSICIANS LN
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City | SOUTHAVEN
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State | MS
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Zip | 38671-9569
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Country | US
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Telephone | 662-655-2136
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Fax | 662-996-2214
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Provider Business Mailing Address
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Address Line | 26500 AGOURA RD STE 102-587
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City | CALABASAS
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State | CA
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Zip | 91302-1952
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Country | US
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Telephone | 818-880-8605
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Fax | 818-579-7916
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 25MA09575600
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License Number State | NJ
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Taxonomy #2
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | MD041221E
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License Number State | PA
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Taxonomy #3
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | C1-0011573
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License Number State | DE
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Taxonomy #4
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Taxonomy Code | 2085R0204X
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Taxonomy Name | Vascular & Interventional Radiology Physician
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License Number | MD041221E
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License Number State | PA
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Taxonomy #5
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Taxonomy Code | 2085R0204X
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Taxonomy Name | Vascular & Interventional Radiology Physician
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License Number | 25MA09575600
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License Number State | NJ
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Taxonomy #6
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Taxonomy Code | 2085R0204X
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Taxonomy Name | Vascular & Interventional Radiology Physician
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License Number | 63241
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License Number State | TN
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Taxonomy #7
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Taxonomy Code | 2085R0204X
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Taxonomy Name | Vascular & Interventional Radiology Physician
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License Number | MD-23034
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License Number State | HI
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Taxonomy #8
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Taxonomy Code | 2085R0204X
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Taxonomy Name | Vascular & Interventional Radiology Physician
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License Number | C1-0011573
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License Number State | DE
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Taxonomy #9
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Taxonomy Code | 2085R0204X
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Taxonomy Name | Vascular & Interventional Radiology Physician
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License Number | 28916
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License Number State | MS
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