Provider Demographics
NPI:1508063314
Name:HARTER, SCOTT MATTHEW (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:MATTHEW
Last Name:HARTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 E MISSOURI AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-1351
Mailing Address - Country:US
Mailing Address - Phone:602-262-8917
Mailing Address - Fax:602-262-8890
Practice Address - Street 1:645 E MISSOURI AVE STE 300
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-1351
Practice Address - Country:US
Practice Address - Phone:602-262-8917
Practice Address - Fax:602-262-8890
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA105704207L00000X
IL036120178207L00000X
WI53084207L00000X
AZ60393207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036120178OtherIL MEDICAL LICENSE
WI53084OtherWI STATE LICENSE
WI002380302Medicare PIN