Provider Demographics
NPI:1275506644
Name:STOLL, SCOTT T (DO, PHD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:T
Last Name:STOLL
Suffix:
Gender:M
Credentials:DO, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5717 EDWARDS RANCH RD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-4116
Mailing Address - Country:US
Mailing Address - Phone:817-294-3195
Mailing Address - Fax:817-294-3466
Practice Address - Street 1:5717 EDWARDS RANCH RD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-4116
Practice Address - Country:US
Practice Address - Phone:817-294-3195
Practice Address - Fax:817-294-3466
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH9575204D00000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8CE992OtherBCBS
TX101368205Medicaid
TX101368202Medicaid
TX84W011OtherBCBS
TX8CE992OtherBCBS
TX84W011OtherBCBS
TXE98001Medicare UPIN
TX101368205Medicaid
TX84W011Medicare PIN