Provider Demographics
NPI:1215007315
Name:PUCKETT, TEDD R (MD)
Entity Type:Individual
Prefix:
First Name:TEDD
Middle Name:R
Last Name:PUCKETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 S FRANKLIN ST STE C
Mailing Address - Street 2:
Mailing Address - City:CHRISTIANSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24073-3547
Mailing Address - Country:US
Mailing Address - Phone:540-381-2013
Mailing Address - Fax:
Practice Address - Street 1:106 S FRANKLIN ST STE C
Practice Address - Street 2:
Practice Address - City:CHRISTIANSBURG
Practice Address - State:VA
Practice Address - Zip Code:24073-3547
Practice Address - Country:US
Practice Address - Phone:540-381-2013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101058838207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006303293Medicaid
VA0193226OtherGIGNA
VT258585OtherANTHEM (BLUE CROSS)
VA006303200Medicaid
VA5978709OtherAETNA
VA0800644OtherUNITED HEALTHCARE
VA452768OtherANTHEM (BLUE CROSS)
VAG86515Medicare UPIN
VA4422950001Medicare NSC
VAVAA100218Medicare PIN
VT258585OtherANTHEM (BLUE CROSS)
VA5978709OtherAETNA
VA180041974Medicare ID - Type UnspecifiedRAILROAD MEDICARE