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General NPI Number Information
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NPI Number | 1205044146
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Entity Type | Individual
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Provider Name | JUSTIN DAVID PUCKETT DO
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Gender | Male
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Dates
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Enumeration Date | 05/21/2007
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Last Update Date | 09/26/2018
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Provider Practice Location Address
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Address Line | 2004 N BALTIMORE ST STE A
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City | KIRKSVILLE
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State | MO
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Zip | 63501-5107
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Country | US
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Telephone | 660-665-7575
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Fax | 660-665-7576
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Provider Business Mailing Address
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Address Line | PO BOX 551
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City | HANNIBAL
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State | MO
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Zip | 63401-0551
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Country | US
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Telephone | 660-665-7575
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Fax | 660-665-7576
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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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 2006017939
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 2007018127
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License Number State | MO
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