Provider Demographics
NPI:1164808077
Name:SCOTT, CORRY (OD)
Entity Type:Individual
Prefix:
First Name:CORRY
Middle Name:
Last Name:SCOTT
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 1:220 N ADAIR ST
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:OR
Mailing Address - Zip Code:97113-8404
Mailing Address - Country:US
Mailing Address - Phone:503-207-0630
Mailing Address - Fax:
Practice Address - Street 1:220 N ADAIR ST
Practice Address - Street 2:
Practice Address - City:CORNELIUS
Practice Address - State:OR
Practice Address - Zip Code:97113-8404
Practice Address - Country:US
Practice Address - Phone:503-207-0630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-03
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3658ATI152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist