Provider Demographics
NPI:1407527583
Name:MEYER, SCOTT LEE (IDC)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:LEE
Last Name:MEYER
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 COAST GUARD BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23703-2135
Mailing Address - Country:US
Mailing Address - Phone:757-483-8730
Mailing Address - Fax:
Practice Address - Street 1:4000 COAST GUARD BLVD
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23703-2135
Practice Address - Country:US
Practice Address - Phone:757-483-8730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-28
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
Provider Identifiers
StateIdentifier IDID TypeIssuer
1387774641OtherTRICARE