Provider Demographics
NPI:1962638031
Name:PUTZIER, PRISCILLA M (DO)
Entity Type:Individual
Prefix:DR
First Name:PRISCILLA
Middle Name:M
Last Name:PUTZIER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50309-1406
Mailing Address - Country:US
Mailing Address - Phone:515-241-5926
Mailing Address - Fax:515-241-5127
Practice Address - Street 1:1200 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50309-1406
Practice Address - Country:US
Practice Address - Phone:515-241-5926
Practice Address - Fax:515-241-5127
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-03
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-7500208000000X, 2080P0204X
IA4290208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1962638031Medicaid