Provider Demographics
NPI:1598284283
Name:SCOTT, DOMONIC TEHERAN
Entity Type:Individual
Prefix:
First Name:DOMONIC
Middle Name:TEHERAN
Last Name:SCOTT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 BREWER AVE
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-5602
Mailing Address - Country:US
Mailing Address - Phone:757-602-0544
Mailing Address - Fax:
Practice Address - Street 1:102 BREWER AVE
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434
Practice Address - Country:US
Practice Address - Phone:757-288-6833
Practice Address - Fax:757-272-0626
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-13
Last Update Date:2017-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT60356518172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver