Provider Demographics
NPI:1003880626
Name:SCAGLIA, BENNETT PETER (MD)
Entity Type:Individual
Prefix:DR
First Name:BENNETT
Middle Name:PETER
Last Name:SCAGLIA
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 1:311 N CLYDE MORRIS BLVD STE 480
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2766
Mailing Address - Country:US
Mailing Address - Phone:386-425-4199
Mailing Address - Fax:386-425-4680
Practice Address - Street 1:311 N CLYDE MORRIS BLVD
Practice Address - Street 2:SUITE 360
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2781
Practice Address - Country:US
Practice Address - Phone:386-254-4199
Practice Address - Fax:386-947-4680
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG88428208800000X
NY175031208800000X
IL036088435208800000X
FLME103036208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL.36088435Medicaid
IL5007705OtherBLUE CROSS/BLUE SHIELD IL
FL000954100Medicaid
IL5007705OtherBLUE CROSS/BLUE SHIELD IL
ILIL2868099Medicare PIN
FLF78597Medicare UPIN
FLBS580ZMedicare PIN
IL.36088435Medicaid