Provider Demographics
NPI:1558987354
Name:BAUER, SCOTT ALAN (OD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:ALAN
Last Name:BAUER
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 1:196 OLYMPIC DR
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22554-7751
Mailing Address - Country:US
Mailing Address - Phone:208-403-5105
Mailing Address - Fax:
Practice Address - Street 1:3259 CATLIN AVE
Practice Address - Street 2:
Practice Address - City:QUANTICO
Practice Address - State:VA
Practice Address - Zip Code:22134-5109
Practice Address - Country:US
Practice Address - Phone:703-784-1631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-18
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4518152W00000X
VA0618002974152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist