Provider Demographics
NPI:1508835661
Name:PUCKETT, ROBERT J JR (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:PUCKETT
Suffix:JR
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 1:221 TECHNOLOGY PKWY NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1369
Mailing Address - Country:US
Mailing Address - Phone:762-235-1000
Mailing Address - Fax:
Practice Address - Street 1:5470 MARTHA BERRY HWY
Practice Address - Street 2:
Practice Address - City:ARMUCHEE
Practice Address - State:GA
Practice Address - Zip Code:30105-2302
Practice Address - Country:US
Practice Address - Phone:706-235-1156
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050423207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000918981FMedicaid
GA000918981FMedicaid
GA08CBBTZMedicare ID - Type Unspecified