Basic Information
| Provider Information | |||||||||
| NPI: | 1306938022 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PUCKETT | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | WILLIS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 520 SUPERIOR AVE | ||||||||
| Address2: | #370 | ||||||||
| City: | NEWPORT BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926633637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9495747176 | ||||||||
| FaxNumber: | 9495747180 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 SUPERIOR AVE | ||||||||
| Address2: | #370 | ||||||||
| City: | NEWPORT BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926633637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9495747176 | ||||||||
| FaxNumber: | 9495747180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2006 | ||||||||
| LastUpdateDate: | 01/27/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | G38172A | CA | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
No ID Information.