Provider Demographics
NPI:1235138744
Name:SCOTT, RANDALL PERRY (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:PERRY
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 1:930 N. SWITZER CANYON DR.
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001
Mailing Address - Country:US
Mailing Address - Phone:928-779-5707
Mailing Address - Fax:928-779-7897
Practice Address - Street 1:930 N. SWITZER CANYON DR.
Practice Address - Street 2:SUITE 202
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001
Practice Address - Country:US
Practice Address - Phone:928-779-5707
Practice Address - Fax:928-779-5737
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-18
Last Update Date:2015-09-03
Deactivation Date:2006-03-18
Deactivation Code:
Reactivation Date:2006-04-05
Provider Licenses
StateLicense IDTaxonomies
AZ27944207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
Z280924Medicare PIN
E61567Medicare UPIN
AZE61567Medicare UPIN
AZE61567Medicare UPIN