Provider Demographics
NPI:1447387048
Name:SCOTT, GORDON QUATLEBAUM JR (OPTICIAN)
Entity Type:Individual
Prefix:MR
First Name:GORDON
Middle Name:QUATLEBAUM
Last Name:SCOTT
Suffix:JR
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:411 COMMERCE DR NE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223
Mailing Address - Country:US
Mailing Address - Phone:803-254-9381
Mailing Address - Fax:803-254-1978
Practice Address - Street 1:1812 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-3549
Practice Address - Country:US
Practice Address - Phone:803-254-9381
Practice Address - Fax:803-254-1978
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC352156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDV0105Medicaid