Provider Demographics
NPI:1770501819
Name:PUCKETT, SAMUEL MACK (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:MACK
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 1:1829 CROWE LN
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37821-7264
Mailing Address - Country:US
Mailing Address - Phone:423-623-0653
Mailing Address - Fax:423-625-8264
Practice Address - Street 1:1829 CROWE LN
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:TN
Practice Address - Zip Code:37821-7264
Practice Address - Country:US
Practice Address - Phone:423-623-0653
Practice Address - Fax:423-625-8264
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD16317208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3015182Medicaid
TN3015183Medicare ID - Type Unspecified
TNA97916Medicare UPIN