Provider Demographics
NPI:1023066404
Name:PUTNAM, SAMUEL GRADY (MD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:GRADY
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 1:26500 AGOURA RD STE 102-587
Mailing Address - Street 2:
Mailing Address - City:CALABASAS
Mailing Address - State:CA
Mailing Address - Zip Code:91302-1952
Mailing Address - Country:US
Mailing Address - Phone:818-880-8605
Mailing Address - Fax:818-579-7916
Practice Address - Street 1:55 PHYSICIANS LN
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9569
Practice Address - Country:US
Practice Address - Phone:662-655-2136
Practice Address - Fax:662-996-2214
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2025-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA095756002085R0202X, 2085R0204X
PAMD041221E2085R0202X, 2085R0204X
DEC1-00115732085R0202X, 2085R0204X
TN632412085R0204X
HIMD-230342085R0204X
MS289162085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1172545OtherAETNA HMO
PA30026885OtherKEYSTONE MERCY
PA0012723560016Medicaid
PA0546464000OtherAMERIHEALTH/INTERCOUNTY
PA300099781OtherRRM
PA7929044OtherAETNA PPO
PA0546464000OtherIBC - PC/KHPE
PA710371OtherHIGHMARK BLUE SHIELD
PA8215722OtherCIGNA HMO/PPO
PA710371T92Medicare ID - Type UnspecifiedHGSA
PA0012723560016Medicaid