Provider Demographics
NPI:1396981908
Name:PUCKETT, JOHN MARTIN (LMT)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:MARTIN
Last Name:PUCKETT
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:661 WEST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:BLANCHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:45107
Mailing Address - Country:US
Mailing Address - Phone:937-783-4535
Mailing Address - Fax:937-783-0009
Practice Address - Street 1:453 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:MOUNT ORAB
Practice Address - State:OH
Practice Address - Zip Code:45154
Practice Address - Country:US
Practice Address - Phone:937-783-4535
Practice Address - Fax:937-783-0009
Is Sole Proprietor?:No
Enumeration Date:2009-01-02
Last Update Date:2009-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH015389171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor