Provider Demographics
NPI:1093883795
Name:PUTNAM, THOMAS J (M D)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:J
Last Name:PUTNAM
Suffix:
Gender:M
Credentials:M D
Other - Prefix:DR
Other - First Name:T.
Other - Middle Name:JOSEPH
Other - Last Name:PUTNAM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:M D
Mailing Address - Street 1:PO BOX 788
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38829-0788
Mailing Address - Country:US
Mailing Address - Phone:662-720-3000
Mailing Address - Fax:662-720-3069
Practice Address - Street 1:100 HOSPITAL ST STE 200
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38829-3354
Practice Address - Country:US
Practice Address - Phone:662-720-3000
Practice Address - Fax:662-720-3069
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS09729207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00014401Medicaid
MSD72158Medicare UPIN
MS00014401Medicaid