Basic Information
| Provider Information | |||||||||
| NPI: | 1831150960 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PUCKETT | ||||||||
| FirstName: | BRETT | ||||||||
| MiddleName: | CHRISTOPHER | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6500 BOWDEN RD | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322168070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046340640 | ||||||||
| FaxNumber: | 9046340203 | ||||||||
| Practice Location | |||||||||
| Address1: | 2627 RIVERSIDE AVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322044712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046340640 | ||||||||
| FaxNumber: | 9046340203 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2006 | ||||||||
| LastUpdateDate: | 03/25/2015 | ||||||||
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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 | 207X00000X | ME91111 | FL | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XS0106X | ME91111 | FL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery |
ID Information
| ID | Type | State | Issuer | Description | 653620401A | 05 | GA | MEDICAID | 2704111-00 | 05 | FL | MEDICAID | P00255887 | 01 | FL | RAILROAD MEDICARE | OTHER |