Provider Demographics
NPI:1619138658
Name:SCOTT, RANDALL (DO)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:
Last Name:SCOTT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3189 HIGHWAY 17
Mailing Address - Street 2:
Mailing Address - City:GREEN COVE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32043-9371
Mailing Address - Country:US
Mailing Address - Phone:904-621-0247
Mailing Address - Fax:904-339-9945
Practice Address - Street 1:3189 HIGHWAY 17
Practice Address - Street 2:
Practice Address - City:GREEN COVE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32043-9371
Practice Address - Country:US
Practice Address - Phone:904-621-0643
Practice Address - Fax:904-621-0644
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-23
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS 11177208D00000X
390200000X
FLOS11177207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program