Provider Demographics
NPI:1629019914
Name:ECENBARGER, SCOTT RICHARD (OD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:RICHARD
Last Name:ECENBARGER
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 1:5751 BYRON CENTER AVE SW
Mailing Address - Street 2:SUITE V
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-9621
Mailing Address - Country:US
Mailing Address - Phone:616-532-2020
Mailing Address - Fax:616-532-2022
Practice Address - Street 1:5751 BYRON CENTER AVE SW
Practice Address - Street 2:SUITE V
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-9621
Practice Address - Country:US
Practice Address - Phone:616-532-2020
Practice Address - Fax:616-532-2022
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004003152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI94-4712563Medicaid
MIU81409Medicare UPIN
WIP38600002Medicare PIN