Provider Demographics
NPI:1710024781
Name:DEPAULIS, SCOTT ALLEN (DC)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:ALLEN
Last Name:DEPAULIS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:935 WILDWOOD RD
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55115-1847
Mailing Address - Country:US
Mailing Address - Phone:651-779-4263
Mailing Address - Fax:651-779-4274
Practice Address - Street 1:935 WILDWOOD RD
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55115-1847
Practice Address - Country:US
Practice Address - Phone:651-779-4263
Practice Address - Fax:651-779-4274
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3150111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNU47692Medicare UPIN