Provider Demographics
NPI:1073748562
Name:DR. FREDRIC PUCKETT, PLLC
Entity Type:Organization
Organization Name:DR. FREDRIC PUCKETT, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FREDRIC
Authorized Official - Middle Name:CLARK
Authorized Official - Last Name:PUCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:972-875-6200
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 101
Practice Address - City:ENNIS
Practice Address - State:TX
Practice Address - Zip Code:75119-5644
Practice Address - Country:US
Practice Address - Phone:972-875-7799
Practice Address - Fax:972-878-3031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-27
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2080303202Medicaid