=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841419454
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOHN W PUCKETT MD FACS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2007
-----------------------------------------------------
Last Update Date | 02/03/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 520 SUPERIOR AVE. #370
-----------------------------------------------------
City | NEWPORT BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92663-3623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-574-7176
-----------------------------------------------------
Fax | 979-574-7180
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 520 SUPERIOR AVE #370
-----------------------------------------------------
City | NEWPORT BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92663-3637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-574-7176
-----------------------------------------------------
Fax | 979-574-7180
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VASCULAR SURGEON
-----------------------------------------------------
Name | DR. JOHN WILLIS PUCKETT
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 949-574-7176
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2086S0129X
-----------------------------------------------------
Taxonomy Name | Vascular Surgery Physician
-----------------------------------------------------
License Number | G38172A
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------