Provider Demographics
NPI:1417938176
Name:PUTNAM, PETER (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:PUTNAM
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:PO BOX 23340
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63156-3340
Mailing Address - Country:US
Mailing Address - Phone:314-965-5437
Mailing Address - Fax:314-965-5439
Practice Address - Street 1:9930 WATSON RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63126-1827
Practice Address - Country:US
Practice Address - Phone:314-965-5437
Practice Address - Fax:314-965-5439
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO113311208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO96948OtherGHP
MO23561V3431OtherHEALTHCARE USA
MO7432234OtherAETNA
MO143223OtherBCBS
MO143223OtherBLUE CHOICE
MO431383893PUTOtherMERCY
MO1200670OtherUHC
MO456440OtherHEALTHLINK