Provider Demographics
NPI:1639203169
Name:WITHERSPOON, SCOTT ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:ROBERT
Last Name:WITHERSPOON
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 1:3414 OAK GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-2375
Mailing Address - Country:US
Mailing Address - Phone:214-521-1153
Mailing Address - Fax:214-219-3651
Practice Address - Street 1:3414 OAK GROVE AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-2375
Practice Address - Country:US
Practice Address - Phone:214-521-1153
Practice Address - Fax:214-219-3651
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN2885207W00000X, 207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8L15466Medicare PIN
TX8L15468Medicare PIN
TX8L15467Medicare PIN