Provider Demographics
NPI:1083714612
Name:SCOTT, JONETTE (MD)
Entity Type:Individual
Prefix:
First Name:JONETTE
Middle Name:
Last Name:SCOTT
Suffix:
Gender:F
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:PO BOX 475
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39533-0475
Mailing Address - Country:US
Mailing Address - Phone:228-374-2494
Mailing Address - Fax:228-374-0856
Practice Address - Street 1:15024 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-8306
Practice Address - Country:US
Practice Address - Phone:228-864-0003
Practice Address - Fax:228-863-7917
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS12293208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00012401Medicaid
MS370000228Medicare ID - Type Unspecified
MSC42726Medicare UPIN