Provider Demographics
NPI:1366411431
Name:PUTTHOFF, STEPHEN L (DO)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:L
Last Name:PUTTHOFF
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 CAMP BOWIE BLVD
Mailing Address - Street 2:UNTHSC DEPT. OF QUALITY MANAGEMENT. EAD 324
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107
Mailing Address - Country:US
Mailing Address - Phone:817-735-0111
Mailing Address - Fax:
Practice Address - Street 1:3500 CAMP BOWIE BLVD
Practice Address - Street 2:EAD 318
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-2644
Practice Address - Country:US
Practice Address - Phone:817-735-2429
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH2164207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CLO426OtherBLUE CROSS AND BLUE SHIEL
CLO426OtherBLUE CROSS AND BLUE SHIEL
TXE28657Medicare UPIN