Provider Demographics
NPI:1831274141
Name:PUCKETT, LOY C (MD)
Entity type:Individual
Prefix:
First Name:LOY
Middle Name:C
Last Name:PUCKETT
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 1:4108 FALL RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-6629
Mailing Address - Country:US
Mailing Address - Phone:573-445-3926
Mailing Address - Fax:
Practice Address - Street 1:1515 UNION AVE
Practice Address - Street 2:
Practice Address - City:MOBERLY
Practice Address - State:MO
Practice Address - Zip Code:65270-9407
Practice Address - Country:US
Practice Address - Phone:660-269-3157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO101050207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO101050OtherLICENSE
116134OtherBLUE CROSS/BLUE SHIELD
A13715Medicare UPIN