Provider Demographics
NPI:1518950724
Name:GEBHARDT, SCOTT M (DO)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:M
Last Name:GEBHARDT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2264 DOG LEG CT
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34604-1000
Mailing Address - Country:US
Mailing Address - Phone:352-585-2422
Mailing Address - Fax:
Practice Address - Street 1:2264 DOG LEG CT
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34604-1000
Practice Address - Country:US
Practice Address - Phone:352-585-2422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-24
Last Update Date:2009-08-27
Deactivation Date:2006-03-25
Deactivation Code:
Reactivation Date:2006-04-12
Provider Licenses
StateLicense IDTaxonomies
FLOS8060207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL264181000Medicaid
FLK8811Medicare UPIN