Provider Demographics
NPI:1518278340
Name:PUTHOFF, GAVIN (MD)
Entity Type:Individual
Prefix:
First Name:GAVIN
Middle Name:
Last Name:PUTHOFF
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 1:621 S NEW BALLAS RD
Mailing Address - Street 2:SUITE 1015B
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8232
Mailing Address - Country:US
Mailing Address - Phone:314-251-8965
Mailing Address - Fax:314-251-8966
Practice Address - Street 1:621 S NEW BALLAS RD
Practice Address - Street 2:SUITE 1015B
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8232
Practice Address - Country:US
Practice Address - Phone:314-251-8965
Practice Address - Fax:314-251-8966
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-25
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE27763207V00000X
MO2013039277207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology