Provider Demographics
NPI:1407358740
Name:KOHLERT, SCOTT FRASER (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:FRASER
Last Name:KOHLERT
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 1:1136 E GRANDE BLVD
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-3982
Mailing Address - Country:US
Mailing Address - Phone:903-592-5601
Mailing Address - Fax:
Practice Address - Street 1:910 E HOUSTON ST STE 530
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-8366
Practice Address - Country:US
Practice Address - Phone:903-606-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-02
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR5582207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1N9534OtherMEDICARE