Provider Demographics
NPI:1063457422
Name:BROTHERSON, SCOTT KIRK (OD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:KIRK
Last Name:BROTHERSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 N WILLOW ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MESQUITE
Mailing Address - State:NV
Mailing Address - Zip Code:89027-4785
Mailing Address - Country:US
Mailing Address - Phone:702-346-3031
Mailing Address - Fax:
Practice Address - Street 1:61 N WILLOW ST
Practice Address - Street 2:SUITE 2
Practice Address - City:MESQUITE
Practice Address - State:NV
Practice Address - Zip Code:89027-4785
Practice Address - Country:US
Practice Address - Phone:702-346-3031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV327152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVU68679Medicare UPIN
NVGP507ZMedicare PIN