Provider Demographics
NPI:1629066956
Name:KING, SCOTT BYRON (DPM)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:BYRON
Last Name:KING
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:OTTUMWA
Mailing Address - State:IA
Mailing Address - Zip Code:52501-4216
Mailing Address - Country:US
Mailing Address - Phone:641-575-2054
Mailing Address - Fax:641-575-2057
Practice Address - Street 1:515 CHURCH ST
Practice Address - Street 2:
Practice Address - City:OTTUMWA
Practice Address - State:IA
Practice Address - Zip Code:52501-4216
Practice Address - Country:US
Practice Address - Phone:641-575-2054
Practice Address - Fax:641-575-2057
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00453213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0249003Medicaid
IAT01418Medicare UPIN
IA0249003Medicaid
IA1109550002Medicare NSC