Provider Demographics
NPI:1700885977
Name:PUTTLER, OLIVER L JR (MD)
Entity Type:Individual
Prefix:
First Name:OLIVER
Middle Name:L
Last Name:PUTTLER
Suffix:JR
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 1:3798 JANES RD
Mailing Address - Street 2:SUITE 15
Mailing Address - City:ARCATA
Mailing Address - State:CA
Mailing Address - Zip Code:95521-4753
Mailing Address - Country:US
Mailing Address - Phone:707-822-1131
Mailing Address - Fax:707-822-0746
Practice Address - Street 1:3798 JANES RD
Practice Address - Street 2:SUITE 15
Practice Address - City:ARCATA
Practice Address - State:CA
Practice Address - Zip Code:95521-4753
Practice Address - Country:US
Practice Address - Phone:707-822-1131
Practice Address - Fax:707-822-0746
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG13904174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G139040Medicaid
CA00G139040Medicare ID - Type Unspecified
CAE60025Medicare UPIN