Provider Demographics
NPI:1477866432
Name:ROLLER, SCOTT ALLAN (IDC)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:ALLAN
Last Name:ROLLER
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 BULLFINCH RD
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32407-7012
Mailing Address - Country:US
Mailing Address - Phone:850-230-3275
Mailing Address - Fax:850-230-3197
Practice Address - Street 1:321 BULLFINCH RD
Practice Address - Street 2:
Practice Address - City:PANAMA CITY BEACH
Practice Address - State:FL
Practice Address - Zip Code:32407-7012
Practice Address - Country:US
Practice Address - Phone:850-230-3275
Practice Address - Fax:850-230-3197
Is Sole Proprietor?:No
Enumeration Date:2010-07-20
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman