Provider Demographics
NPI:1275812091
Name:O L PUTTLER JR MD A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:O L PUTTLER JR MD A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OLIVER
Authorized Official - Middle Name:L
Authorized Official - Last Name:PUTTLER
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:707-822-1131
Mailing Address - Street 1:3798 JANES RD
Mailing Address - Street 2:SUITE 15
Mailing Address - City:ARCATA
Mailing Address - State:CA
Mailing Address - Zip Code:95521-4753
Mailing Address - Country:US
Mailing Address - Phone:707-822-1131
Mailing Address - Fax:707-822-0746
Practice Address - Street 1:3798 JANES RD
Practice Address - Street 2:SUITE 15
Practice Address - City:ARCATA
Practice Address - State:CA
Practice Address - Zip Code:95521-4753
Practice Address - Country:US
Practice Address - Phone:707-822-1131
Practice Address - Fax:707-822-0746
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-10
Last Update Date:2017-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG13904261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G139040Medicaid
CAE60025Medicare UPIN