Provider Demographics
NPI:1003872359
Name:SCOTT, COLIN J (MD)
Entity Type:Individual
Prefix:
First Name:COLIN
Middle Name:J
Last Name:SCOTT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:8921 N WOOD SAGE RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-7822
Mailing Address - Country:US
Mailing Address - Phone:309-243-3869
Mailing Address - Fax:309-243-7918
Practice Address - Street 1:8921 N WOOD SAGE RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-7822
Practice Address - Country:US
Practice Address - Phone:309-243-3869
Practice Address - Fax:309-243-7918
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY248001207W00000X, 2084N0400X
WAMD60294408207W00000X, 2084N0400X
IL036134025207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
A300047882OtherPTAN