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General NPI Number Information
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NPI Number | 1164420477
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Entity Type | Individual
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Provider Name | JAMIE L. PUCKETT M.D.
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Gender | Male
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Dates
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Enumeration Date | 07/11/2005
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Last Update Date | 09/03/2024
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Provider Practice Location Address
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Address Line | 1101 HIGHWAY K
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City | O FALLON
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State | MO
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Zip | 63366-8431
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Country | US
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Telephone | 636-379-6363
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 955534 SUITE 100
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City | SAINT LOUIS
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State | MO
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Zip | 63195-0001
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Country | US
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Telephone |
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Fax |
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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 | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number | 108740
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License Number State | MO
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