Basic Information
| Provider Information | |||||||||
| NPI: | 1275604621 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PUTNAM | ||||||||
| FirstName: | WAYNE | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 802843 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641802843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178753000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3801 S NATIONAL AVE | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658075210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178753000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2006 | ||||||||
| LastUpdateDate: | 09/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X | R8688 | MO | N | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085N0700X | R8688 | MO | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085N0904X | R8688 | MO | N | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085P0229X | R8688 | MO | N | Allopathic & Osteopathic Physicians | Radiology | Pediatric Radiology | 2085R0203X | R8688 | MO | N | Allopathic & Osteopathic Physicians | Radiology | Therapeutic Radiology | 2085R0204X | R8688 | MO | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085U0001X | R8688 | MO | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 2085R0202X | R8688 | MO | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 240698217 | 05 | MO | MEDICAID |