1073748562 NPI number — DR. FREDRIC PUCKETT, PLLC

Table of content: (NPI 1073748562)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073748562 NPI number — DR. FREDRIC PUCKETT, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR. FREDRIC PUCKETT, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073748562
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/05/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2203 W LAMPASAS ST STE 111
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ENNIS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75119-5667
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-875-6200
Provider Business Mailing Address Fax Number:
972-875-6414

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2203 W LAMPASAS ST
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
ENNIS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75119-5644
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-875-7799
Provider Business Practice Location Address Fax Number:
972-878-3031
Provider Enumeration Date:
05/27/2009

Additional Information

Authorized Official

Authorized Official Last Name:
PUCKETT
Authorized Official First Name:
FREDRIC
Authorized Official Middle Name:
CLARK
Authorized Official Title or Position:
PHYSICIAN/OWNER
Authorized Official Telephone Number:
972-875-6200

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2080303202 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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