Provider Demographics
NPI:1124183868
Name:SCOTT, TERRY WESLEY (MD)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:WESLEY
Last Name:SCOTT
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 1:1111 GRAND AVE
Mailing Address - Street 2:# E
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-4171
Mailing Address - Country:US
Mailing Address - Phone:909-860-7712
Mailing Address - Fax:909-861-1311
Practice Address - Street 1:1111 GRAND AVE
Practice Address - Street 2:# E
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-4171
Practice Address - Country:US
Practice Address - Phone:909-860-7712
Practice Address - Fax:909-861-1311
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG54536207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA52740Medicare UPIN