Provider Demographics
NPI:1811429236
Name:PUCKETT, ERNEST ROBERT
Entity type:Individual
Prefix:
First Name:ERNEST
Middle Name:ROBERT
Last Name:PUCKETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 OAK ST STE 7
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-7701
Mailing Address - Country:US
Mailing Address - Phone:541-687-1927
Mailing Address - Fax:541-683-8779
Practice Address - Street 1:1550 OAK ST STE 7
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-7701
Practice Address - Country:US
Practice Address - Phone:541-687-1927
Practice Address - Fax:541-683-8779
Is Sole Proprietor?:No
Enumeration Date:2017-04-03
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ORMD209014207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program