Provider Demographics
NPI:1487857264
Name:PUTNAM, DANIEL S (LMT)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:S
Last Name:PUTNAM
Suffix:
Gender:M
Credentials:LMT
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 380066
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32205-0566
Mailing Address - Country:US
Mailing Address - Phone:904-982-4336
Mailing Address - Fax:800-350-7636
Practice Address - Street 1:1437 FLAGLER AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8516
Practice Address - Country:US
Practice Address - Phone:904-982-4336
Practice Address - Fax:800-350-7636
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA0022782225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC7661OtherBCBS OF FL PROVIDER #
FLMA0022782OtherFLORIDA LICENSE #