Provider Demographics
NPI:1174562813
Name:PUCKETT, KENDALL RYAN (MD)
Entity type:Individual
Prefix:DR
First Name:KENDALL
Middle Name:RYAN
Last Name:PUCKETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:22266 HIGHWAY 25
Mailing Address - Street 2:
Mailing Address - City:COLUMBIANA
Mailing Address - State:AL
Mailing Address - Zip Code:35051-8618
Mailing Address - Country:US
Mailing Address - Phone:205-669-3138
Mailing Address - Fax:205-669-8718
Practice Address - Street 1:22266 HIGHWAY 25
Practice Address - Street 2:
Practice Address - City:COLUMBIANA
Practice Address - State:AL
Practice Address - Zip Code:35051-8618
Practice Address - Country:US
Practice Address - Phone:205-669-3138
Practice Address - Fax:205-669-8718
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL20170207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL9933273Medicaid
AL9933273Medicaid
ALG70777Medicare UPIN