Provider Demographics
NPI:1659359719
Name:PUTNAM, MARIAN HERMAN (MD)
Entity Type:Individual
Prefix:
First Name:MARIAN
Middle Name:HERMAN
Last Name:PUTNAM
Suffix:
Gender:F
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:PO BOX 366336
Mailing Address - Street 2:
Mailing Address - City:HYDE PARK
Mailing Address - State:MA
Mailing Address - Zip Code:02136-0025
Mailing Address - Country:US
Mailing Address - Phone:617-364-6784
Mailing Address - Fax:
Practice Address - Street 1:36 MAPLE ST
Practice Address - Street 2:
Practice Address - City:HYDE PARK
Practice Address - State:MA
Practice Address - Zip Code:02136-2739
Practice Address - Country:US
Practice Address - Phone:617-364-6784
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA39607208000000X, 2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics
Not Answered2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D88566Medicare UPIN