Basic Information
| Provider Information | |||||||||
| NPI: | 1154596765 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PUCKETT | ||||||||
| FirstName: | FREDRIC | ||||||||
| MiddleName: | CLARK | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2203 W LAMPASAS ST STE 111 | ||||||||
| Address2: | |||||||||
| City: | ENNIS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751195667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9728756200 | ||||||||
| FaxNumber: | 9728756414 | ||||||||
| Practice Location | |||||||||
| Address1: | 2203 W LAMPASAS ST | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | ENNIS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751195644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9728756200 | ||||||||
| FaxNumber: | 9728756414 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2008 | ||||||||
| LastUpdateDate: | 04/05/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N1080 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 208303201 | 05 | TX | MEDICAID | 208303202 | 05 | TX | MEDICAID |