Provider Demographics
NPI:1154596765
Name:PUCKETT, FREDRIC CLARK (DO)
Entity type:Individual
Prefix:DR
First Name:FREDRIC
Middle Name:CLARK
Last Name:PUCKETT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2203 W LAMPASAS ST STE 111
Mailing Address - Street 2:
Mailing Address - City:ENNIS
Mailing Address - State:TX
Mailing Address - Zip Code:75119-5667
Mailing Address - Country:US
Mailing Address - Phone:972-875-6200
Mailing Address - Fax:972-875-6414
Practice Address - Street 1:2203 W LAMPASAS ST
Practice Address - Street 2:SUITE 205
Practice Address - City:ENNIS
Practice Address - State:TX
Practice Address - Zip Code:75119-5644
Practice Address - Country:US
Practice Address - Phone:972-875-6200
Practice Address - Fax:972-875-6414
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-24
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN1080207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX208303201Medicaid
TX208303202Medicaid