Provider Demographics
NPI:1689692576
Name:FLORELL, SCOTT R (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:R
Last Name:FLORELL
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 3208
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84110-3208
Mailing Address - Country:US
Mailing Address - Phone:801-587-6340
Mailing Address - Fax:801-587-6346
Practice Address - Street 1:4488 HANALEI PLANTATION RD
Practice Address - Street 2:
Practice Address - City:PRINCEVILLE
Practice Address - State:HI
Practice Address - Zip Code:96722-5462
Practice Address - Country:US
Practice Address - Phone:808-320-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2761741205207N00000X, 207ND0900X
UT276174-1205207NS0135X, 207ZP0102X
HIMD-21397207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI001150Medicaid
NMJ0854Medicaid
OR299802Medicaid
ID806454201Medicaid
UT870468377001Medicaid
NV002082905Medicaid
CA3020636Medicaid
MT0059631Medicaid
GA249747104AMedicaid
WA8416273Medicaid