Provider Demographics
NPI:1679595615
Name:HANNUM, SCOTT R (DO)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:R
Last Name:HANNUM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:720 W OAK ST
Mailing Address - Street 2:SUITE 380
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-4910
Mailing Address - Country:US
Mailing Address - Phone:407-518-4982
Mailing Address - Fax:407-518-1748
Practice Address - Street 1:720 W OAK ST STE 309
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4910
Practice Address - Country:US
Practice Address - Phone:407-518-4982
Practice Address - Fax:407-518-1748
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS87402086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL17027OtherBCBS
FL264703600Medicaid
FLAC947Medicare PIN
FL264703600Medicaid