Provider Demographics
NPI:1376510222
Name:PUCKETT, TERRY LEE (MD, MPH)
Entity type:Individual
Prefix:DR
First Name:TERRY
Middle Name:LEE
Last Name:PUCKETT
Suffix:
Gender:M
Credentials:MD, MPH
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Mailing Address - Street 1:603 CAMPUS DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ABINGDON
Mailing Address - State:VA
Mailing Address - Zip Code:24210-9700
Mailing Address - Country:US
Mailing Address - Phone:276-739-8010
Mailing Address - Fax:276-628-1410
Practice Address - Street 1:24530 FALCON PLACE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:ABINGDON
Practice Address - State:VA
Practice Address - Zip Code:24211-7665
Practice Address - Country:US
Practice Address - Phone:276-619-0075
Practice Address - Fax:276-619-0077
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TNMD 182892083A0100X, 2083X0100X
VA01012412082083A0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1376510222Medicaid
TNQ000141Medicaid
VAP01599940OtherRR MEDICARE
VA1376510222Medicaid
TNQ000141Medicaid
TN103I846166Medicare PIN