MEDICARE: SOUTHEAST ORTHOPEDIC SPECIALISTS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332900000X	Non-Pharmacy Dispensing Site

General Provider Information

NPI Number	:	1992598734
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHEAST ORTHOPEDIC SPECIALISTS, LLC

Provider Business Mailing Address
First Line	:	6800 SOUTHPOINT PKWY STE 300
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32216-8203
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	300 SAINT ELIZABETH WAY STE 210
Second Line	:
City	:	ST JOHNS
State	:	FL
Zip	:	32259-1153
Country	:	US
Telephone Number	:	904-634-0640
Fax Number	:	904-634-0203

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BRETT PUCKETT
Credential	:	MD
Telephone Number	:	904-634-0640

Provider Enumeration Date	:	05/24/2025
Last Update Date	:	05/24/2025

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