Provider Demographics
NPI:1306938022
Name:PUCKETT, JOHN WILLIS (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:WILLIS
Last Name:PUCKETT
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:520 SUPERIOR AVE
Mailing Address - Street 2:#370
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-3637
Mailing Address - Country:US
Mailing Address - Phone:949-574-7176
Mailing Address - Fax:949-574-7180
Practice Address - Street 1:520 SUPERIOR AVE
Practice Address - Street 2:#370
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3637
Practice Address - Country:US
Practice Address - Phone:949-574-7176
Practice Address - Fax:949-574-7180
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2014-01-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG38172A2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
A47381Medicare UPIN
CAG38172AMedicare PIN