Provider Demographics
NPI:1609963750
Name:SCOTT, MICHAEL BERTNICE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:BERTNICE
Last Name:SCOTT
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 1:3637 MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262-3511
Mailing Address - Country:US
Mailing Address - Phone:310-537-9230
Mailing Address - Fax:310-537-9022
Practice Address - Street 1:3637 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-3511
Practice Address - Country:US
Practice Address - Phone:310-537-9230
Practice Address - Fax:310-537-9022
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-09
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG226942088P0231X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric Urology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G226940Medicaid
CAA41678Medicare UPIN
CA00G226940Medicaid