Provider Demographics
NPI:1609857549
Name:PUCKETT, TIM K (MD)
Entity Type:Individual
Prefix:
First Name:TIM
Middle Name:K
Last Name:PUCKETT
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 1:8110 ROYAL PALM BLVD
Mailing Address - Street 2:STE 108
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33065-5795
Mailing Address - Country:US
Mailing Address - Phone:954-341-8288
Mailing Address - Fax:954-341-5156
Practice Address - Street 1:8110 ROYAL PALM BLVD
Practice Address - Street 2:STE 108
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33065-5795
Practice Address - Country:US
Practice Address - Phone:954-341-8288
Practice Address - Fax:954-341-5156
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME93795207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
53106OtherBLUE CROSS BLUE SHIELD
FL273922400Medicaid
FLU6635ZMedicare PIN
F73727Medicare UPIN