Provider Demographics
NPI:1164420477
Name:PUCKETT, JAMIE L (MD)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:L
Last Name:PUCKETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 955534 SUITE 100
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1101 HIGHWAY K
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-8431
Practice Address - Country:US
Practice Address - Phone:636-379-6363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO108740207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO204809008Medicaid
G99615Medicare UPIN
MO204809008Medicaid