Provider Demographics
NPI:1205044146
Name:PUCKETT, JUSTIN DAVID (DO)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:DAVID
Last Name:PUCKETT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 551
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-0551
Mailing Address - Country:US
Mailing Address - Phone:660-665-7575
Mailing Address - Fax:660-665-7576
Practice Address - Street 1:2004 N BALTIMORE ST STE A
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-5107
Practice Address - Country:US
Practice Address - Phone:660-665-7575
Practice Address - Fax:660-665-7576
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006017939207Q00000X
MO2007018127207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA1807001OtherMEDICARE
MO209398502Medicaid