Provider Demographics
NPI:1164420477
Name:PUCKETT, JAMIE L (MD)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:L
Last Name:PUCKETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:201 BJC SAINT PETERS DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-3091
Mailing Address - Country:US
Mailing Address - Phone:636-916-8200
Mailing Address - Fax:636-946-8533
Practice Address - Street 1:201 BJC SAINT PETERS DR
Practice Address - Street 2:SUITE 100
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-3091
Practice Address - Country:US
Practice Address - Phone:636-916-8200
Practice Address - Fax:636-946-8533
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO108740207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO204809008Medicaid
G99615Medicare UPIN
MO204809008Medicaid