Provider Demographics
NPI:1972536308
Name:PUCKETT, STEPHEN C (OD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:C
Last Name:PUCKETT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:3042 SANTA MARIA CT
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94518-2812
Mailing Address - Country:US
Mailing Address - Phone:925-682-1959
Mailing Address - Fax:
Practice Address - Street 1:127 HOSPITAL DR
Practice Address - Street 2:SUITE 201
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589-2500
Practice Address - Country:US
Practice Address - Phone:707-554-3101
Practice Address - Fax:707-554-2402
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA10914T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASDO109140Medicare PIN