Provider Demographics
NPI:1225251820
Name:SCOTT, ETHAN WALTER (MD)
Entity Type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:WALTER
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 1:3428 WHISPER BR
Mailing Address - Street 2:
Mailing Address - City:CIBOLO
Mailing Address - State:TX
Mailing Address - Zip Code:78108-2313
Mailing Address - Country:US
Mailing Address - Phone:210-834-5508
Mailing Address - Fax:
Practice Address - Street 1:3851 ROGER BROOKE DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78234-4501
Practice Address - Country:US
Practice Address - Phone:210-916-8499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-9833207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology