Provider Demographics
NPI:1043222714
Name:WICKLESS, SCOTT C (DO)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:C
Last Name:WICKLESS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:4919 MEMORIAL HWY STE 150
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-7516
Mailing Address - Country:US
Mailing Address - Phone:813-333-1528
Mailing Address - Fax:813-255-2818
Practice Address - Street 1:1801 S OSPREY AVE UNIT 201
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-3625
Practice Address - Country:US
Practice Address - Phone:941-957-4767
Practice Address - Fax:941-955-7334
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS15286207ZD0900X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL107709300Medicaid
COBW9718771OtherDEA
COCO305676OtherMEDICARE