Provider Demographics
NPI:1467545442
Name:THIELE, SCOTT LINDSTROM (OD)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:LINDSTROM
Last Name:THIELE
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 1:9398-1 ARLINGTON EXPRESSWAY
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225
Mailing Address - Country:US
Mailing Address - Phone:904-724-9210
Mailing Address - Fax:
Practice Address - Street 1:9398-1 ARLINGTON EXPRESSWAY
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225
Practice Address - Country:US
Practice Address - Phone:904-724-9210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0PL3973152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist