Provider Demographics
NPI:1467452474
Name:PEARL, SCOTT M (OD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:M
Last Name:PEARL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 LOS CAMINOS ST
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32095-7417
Mailing Address - Country:US
Mailing Address - Phone:954-655-8330
Mailing Address - Fax:
Practice Address - Street 1:535 LOS CAMINOS ST
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32095-7417
Practice Address - Country:US
Practice Address - Phone:954-655-8330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-01
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC001954152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
19558VMedicare PIN
FL19558Medicare ID - Type Unspecified