Provider Demographics
NPI:1235837774
Name:IVY, SCOTT DOUGLAS
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:DOUGLAS
Last Name:IVY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11004 ROCKLEDGE VIEW DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33579-2370
Mailing Address - Country:US
Mailing Address - Phone:813-531-2383
Mailing Address - Fax:813-922-0223
Practice Address - Street 1:11004 ROCKLEDGE VIEW DR
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33579-2370
Practice Address - Country:US
Practice Address - Phone:813-531-2383
Practice Address - Fax:813-922-0223
Is Sole Proprietor?:No
Enumeration Date:2023-02-22
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL372500000X, 175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No372500000XNursing Service Related ProvidersChore Provider