Provider Demographics
NPI:1760447288
Name:PUTNAM, THEODORE INMAN (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:INMAN
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 1:4511 HARLEM ROAD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14226-3822
Mailing Address - Country:US
Mailing Address - Phone:716-839-6720
Mailing Address - Fax:716-839-6740
Practice Address - Street 1:219 BRYANT ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14222-2006
Practice Address - Country:US
Practice Address - Phone:716-878-7109
Practice Address - Fax:716-888-3874
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY095973208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
00010142001OtherUNIVERA
040426002230OtherFIDELIS
PA0014382740001Medicaid
000503501002OtherBC/BS
NY00639423Medicaid
051028000061OtherUNIVERA
061102000045OtherFIDELIS
1211171OtherIHA
000503501004OtherBC/BS
000503501005OtherBC/BS
PA0014382740001Medicaid
NY00639423Medicaid