Provider Demographics
NPI:1558361543
Name:SMOLLER, SCOTT DANA (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:DANA
Last Name:SMOLLER
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 1:180 SW 84TH AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-2731
Mailing Address - Country:US
Mailing Address - Phone:954-452-5188
Mailing Address - Fax:954-474-0277
Practice Address - Street 1:180 SW 84TH AVE
Practice Address - Street 2:SUITE C
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-2731
Practice Address - Country:US
Practice Address - Phone:954-452-5188
Practice Address - Fax:954-474-0277
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-31
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL36893207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0468797Medicaid
AD715Medicare PIN
FLD79565Medicare UPIN
FL0468797Medicaid
FLAD715Medicare PIN
94270Medicare PIN
D79565Medicare UPIN
94270YMedicare PIN
FL94270YMedicare PIN