Provider Demographics
NPI:1093924276
Name:HOLTHUSEN, SCOTT MYRON (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:MYRON
Last Name:HOLTHUSEN
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 1:560 S MAPLE ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-1733
Mailing Address - Country:US
Mailing Address - Phone:952-442-2163
Mailing Address - Fax:
Practice Address - Street 1:560 S MAPLE ST
Practice Address - Street 2:SUITE 200
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387-1733
Practice Address - Country:US
Practice Address - Phone:952-442-2163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301085937207X00000X
WAMD 60132138207XX0004X
MN54138207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery