Provider Demographics
NPI:1275632176
Name:SCOTT J LOESSIN MD LLC
Entity Type:Organization
Organization Name:SCOTT J LOESSIN MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:J
Authorized Official - Last Name:LOESSIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-258-3223
Mailing Address - Street 1:311 N CLYDE MORRIS BLVD
Mailing Address - Street 2:510
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2781
Mailing Address - Country:US
Mailing Address - Phone:386-258-3223
Mailing Address - Fax:386-252-8237
Practice Address - Street 1:311 N CLYDE MORRIS BLVD
Practice Address - Street 2:SUITE 510
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2781
Practice Address - Country:US
Practice Address - Phone:386-258-3223
Practice Address - Fax:386-252-8237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0067948208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL26863OtherBLUE CROSS/BLUE SHIELD
FL26863OtherBLUE CROSS/BLUE SHIELD
FLK7379Medicare ID - Type Unspecified