Provider Demographics
NPI:1437181724
Name:NORVILLE, SCOTT
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:NORVILLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:933 BRADBURY DR SE
Mailing Address - Street 2:SUITE 2222
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4374
Mailing Address - Country:US
Mailing Address - Phone:505-272-3120
Mailing Address - Fax:
Practice Address - Street 1:2211 LOMAS BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-2719
Practice Address - Country:US
Practice Address - Phone:505-272-1670
Practice Address - Fax:505-272-4435
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ6635207R00000X
NMMD2012-0863207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX129816810Medicaid
TXF91040Medicare UPIN
TX8D8451Medicare ID - Type Unspecified