Provider Demographics
NPI:1851484422
Name:PUCKETT, DEREK WADE (RPT)
Entity Type:Individual
Prefix:MR
First Name:DEREK
Middle Name:WADE
Last Name:PUCKETT
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 HWY 49 SOUTH
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:MS
Mailing Address - Zip Code:39073
Mailing Address - Country:US
Mailing Address - Phone:601-845-8282
Mailing Address - Fax:601-845-8290
Practice Address - Street 1:3000 HWY 49 SOUTH
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:MS
Practice Address - Zip Code:39073
Practice Address - Country:US
Practice Address - Phone:601-845-8282
Practice Address - Fax:601-845-8290
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2011-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT1702225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00116390Medicaid
MS650000106Medicare ID - Type UnspecifiedPROVIDER NUMBER