Provider Demographics
NPI:1629056189
Name:SCOTT, JACK D (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:D
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:PO BOX 918025
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-8025
Mailing Address - Country:US
Mailing Address - Phone:352-265-5911
Mailing Address - Fax:352-265-5606
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3003
Practice Address - Country:US
Practice Address - Phone:352-265-5911
Practice Address - Fax:352-265-5606
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01072522A207P00000X, 207PE0004X
FLME0069637207PE0004X
FLME69637207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL28263OtherBCBS
FLP00162734OtherRRMCR
FL250686600Medicaid
FL28263OtherBCBS
FL28263TMedicare ID - Type Unspecified
FL28263LMedicare PIN
FLF42501Medicare UPIN
FL250686600Medicaid