Physician Compare National (NPI:1154596765)

HEALTHCARE PROVIDER: FREDRIC CLARK PUCKETT D.O.

Physician Compare National contains general information about individual eligible professionals (EPs) such as demographic information and Medicare quality program participation.

Individual Professional Information
NPI	1154596765
	Unique healthcare provider (clinician) ID assigned by NPPES
PECOS UID	5890848329
	Unique individual clinician ID assigned by PECOS
Professional Enrollment ID	I20090731000397
	Unique ID for the individual professional enrollment that is the source for the data in the observation
Provider Last Name	PUCKETT
	Individual professional last name
Provider First Name	FREDRIC
	Individual professional first name
Provider Middle Name	C
	Individual professional middle name
Provider Gender	M
	The provider's gender if the provider is a person.

Medical School Information
Medical School Name	OTHER
	Individual professional's medical school
Graduation Year	2006
	Individual professional's medical school graduation year
Primary Specialty	FAMILY MEDICINE
	Primary medical specialty reported by the individual professional in the selected enrollment

Practice Information
Line 1 Street Address	2203 W LAMPASAS ST
	Group Practice or individual's line 1 address
Line 2 Street Address	SUITE 111
	Group Practice or individual's line 2 address
City	ENNIS
	Group Practice or individual's city
State	TX
	Group Practice or individual's state
Zip Code	751195667
	Group Practice or individual's zip code (9 digits when available)

Hospital(s) Affiliation Information
Hospital Affiliation CCN 1	450833
	Medicare CCN of hospital where individual professional provides service 1
Hospital Affiliation LBN 1	ENNIS REGIONAL MEDICAL CENTER
	Legal business name of hospital where individual professional provides service 1
Professional Accepts Medicare Assignment	Y