Provider Demographics
NPI:1568428803
Name:PUTNAM, LARRY P (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:P
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 1:5700 E PIMA
Mailing Address - Street 2:SUITE E
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712
Mailing Address - Country:US
Mailing Address - Phone:520-324-2030
Mailing Address - Fax:520-324-2619
Practice Address - Street 1:5700 E PIMA
Practice Address - Street 2:SUITE E
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712
Practice Address - Country:US
Practice Address - Phone:520-324-2030
Practice Address - Fax:520-324-2619
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9233207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ236473Medicaid
AZ236473Medicaid
05WCHBF13Medicare ID - Type Unspecified