Provider Demographics
NPI:1285828517
Name:INTRABARTOLO, SCOTT DAVID (CRT)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:DAVID
Last Name:INTRABARTOLO
Suffix:
Gender:M
Credentials:CRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1564
Mailing Address - Street 2:
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92074-1564
Mailing Address - Country:US
Mailing Address - Phone:858-679-8770
Mailing Address - Fax:
Practice Address - Street 1:11995 MOUNTAIN PASS RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-5261
Practice Address - Country:US
Practice Address - Phone:858-679-8770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-29
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARHF48582247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist