Provider Demographics
NPI:1467487744
Name:SCOTT, HENRY KEITH (OD)
Entity Type:Individual
Prefix:DR
First Name:HENRY
Middle Name:KEITH
Last Name:SCOTT
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 1:214 EAST 4TH STREET
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801
Mailing Address - Country:US
Mailing Address - Phone:479-968-3937
Mailing Address - Fax:479-967-6731
Practice Address - Street 1:214 EAST 4TH ST
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801
Practice Address - Country:US
Practice Address - Phone:479-968-3937
Practice Address - Fax:479-967-6731
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2349152W00000X
AROD1100234152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR148782722Medicaid
AR48954Medicare ID - Type Unspecified
AR148782722Medicaid