Provider Demographics
NPI:1679576615
Name:PUTLAND, MICHAEL STUART (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:STUART
Last Name:PUTLAND
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14200 W FILLMORE ST
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-3005
Mailing Address - Country:US
Mailing Address - Phone:623-207-3000
Mailing Address - Fax:
Practice Address - Street 1:14200 W FILLMORE ST
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-3005
Practice Address - Country:US
Practice Address - Phone:623-207-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME88971207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL82513OtherINDIVIDUAL BCBS ID NUMBER
FL99039OtherGROUP BCBS ID NUMBER
GA000925383BMedicaid
FLAJ564OtherMEDICARE GIN
FL268691100Medicaid
FLP00625816OtherMEDICARE RAIL ROAD
FL99039OtherGROUP BCBS ID NUMBER
FL82513AMedicare ID - Type Unspecified
FL82513ZMedicare PIN