Provider Demographics
NPI:1376526392
Name:PUZDRAKIEWICZ, MICHELLE GRACE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:GRACE
Last Name:PUZDRAKIEWICZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1804 HIGHWAY 45 BYP STE 604
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-4403
Mailing Address - Country:US
Mailing Address - Phone:731-660-7971
Mailing Address - Fax:731-660-8739
Practice Address - Street 1:1700 WOODLAWN AVE
Practice Address - Street 2:
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024-2028
Practice Address - Country:US
Practice Address - Phone:731-287-4500
Practice Address - Fax:731-287-4804
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA308800208000000X
TN42447208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1510509Medicaid
TN103I372296Medicare PIN