Provider Demographics
NPI:1205804812
Name:PUTNAM OBSTETRICS AND GYNECOLOGY PA
Entity type:Organization
Organization Name:PUTNAM OBSTETRICS AND GYNECOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMED
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:AKHIYAT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-325-0826
Mailing Address - Street 1:6061 SAINT JOHNS AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-6857
Mailing Address - Country:US
Mailing Address - Phone:386-325-0826
Mailing Address - Fax:386-325-6419
Practice Address - Street 1:6061 SAINT JOHNS AVE
Practice Address - Street 2:SUITE A
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-6857
Practice Address - Country:US
Practice Address - Phone:386-325-0826
Practice Address - Fax:386-325-6419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-09
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL660162600Medicaid
FL660162601Medicaid
FL660162601Medicaid