Provider Demographics
NPI:1073504676
Name:REAM, SCOTT R (OD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:R
Last Name:REAM
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:PO BOX 157
Mailing Address - Street 2:
Mailing Address - City:THAYER
Mailing Address - State:MO
Mailing Address - Zip Code:65791-0157
Mailing Address - Country:US
Mailing Address - Phone:417-264-7418
Mailing Address - Fax:417-264-2838
Practice Address - Street 1:207 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:THAYER
Practice Address - State:MO
Practice Address - Zip Code:65791-1203
Practice Address - Country:US
Practice Address - Phone:417-264-7418
Practice Address - Fax:417-264-2838
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02734152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR115216722Medicaid
MO312553506Medicaid
MO312553506Medicaid
MO000091295Medicare PIN
MOT42799Medicare UPIN