Provider Demographics
NPI:1184910507
Name:PUCKETT, TIMOTHY O'DELL (DPT)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:O'DELL
Last Name:PUCKETT
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12047 STONEY XING
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78247-3453
Mailing Address - Country:US
Mailing Address - Phone:210-387-6993
Mailing Address - Fax:210-855-2542
Practice Address - Street 1:7007 BANDERA RD STE 3
Practice Address - Street 2:
Practice Address - City:LEON VALLEY
Practice Address - State:TX
Practice Address - Zip Code:78238-1264
Practice Address - Country:US
Practice Address - Phone:210-387-6993
Practice Address - Fax:210-855-2542
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-23
Last Update Date:2018-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1206227225100000X, 2251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX290438501Medicaid
TX12284562OtherCAQH
TX867T19OtherBCBSTX
TX867T19OtherBCBSTX
TX12284562OtherCAQH