Provider Demographics
NPI:1518955996
Name:EMERSON, SCOTT SIDNEY (OD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:SIDNEY
Last Name:EMERSON
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 1:1030 W I ST
Mailing Address - Street 2:
Mailing Address - City:LOS BANOS
Mailing Address - State:CA
Mailing Address - Zip Code:93635-3954
Mailing Address - Country:US
Mailing Address - Phone:209-826-2323
Mailing Address - Fax:209-826-2501
Practice Address - Street 1:1030 W I ST
Practice Address - Street 2:
Practice Address - City:LOS BANOS
Practice Address - State:CA
Practice Address - Zip Code:93635-3954
Practice Address - Country:US
Practice Address - Phone:209-826-2323
Practice Address - Fax:209-826-2501
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10483T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0104830Medicaid
U58671Medicare UPIN
CA6098170001Medicare NSC
CASD0104830Medicaid