Provider Demographics
NPI:1215198668
Name:NILSSON, SCOTT THOMAS (OD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:THOMAS
Last Name:NILSSON
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 1:2000 GENERAL BOOTH BLVD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-5876
Mailing Address - Country:US
Mailing Address - Phone:575-426-2020
Mailing Address - Fax:
Practice Address - Street 1:2000 GENERAL BOOTH BLVD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-5876
Practice Address - Country:US
Practice Address - Phone:575-426-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-18
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001752152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1427498344OtherGROUP NPI
VA1215198668Medicare PIN