Provider Demographics
NPI:1457481418
Name:SCOTT L GOLD MD LLC
Entity Type:Organization
Organization Name:SCOTT L GOLD MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:L
Authorized Official - Last Name:GOLD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-984-2133
Mailing Address - Street 1:1535 W NASA BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901
Mailing Address - Country:US
Mailing Address - Phone:321-984-2133
Mailing Address - Fax:321-984-2113
Practice Address - Street 1:1535 W NASA BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901
Practice Address - Country:US
Practice Address - Phone:321-984-2133
Practice Address - Fax:321-984-2113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME421302084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL05474OtherBLUE CROSS BLUE SHIELD
FL4038971OtherAETNA
D51309Medicare UPIN
FL05474OtherBLUE CROSS BLUE SHIELD