Provider Demographics
NPI:1578186656
Name:PUCKETT, SCOTT LOUIS (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:LOUIS
Last Name:PUCKETT
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4502 E 41ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-2536
Mailing Address - Country:US
Mailing Address - Phone:918-619-4400
Mailing Address - Fax:
Practice Address - Street 1:4502 E 41ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-2536
Practice Address - Country:US
Practice Address - Phone:504-638-8572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-22
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK390200000X
390200000X
OK38306208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program