Provider Demographics
NPI:1720011547
Name:WALLER, SCOTT (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:
Last Name:WALLER
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 1:2 TRAP FALLS RD STE 404
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-7622
Mailing Address - Country:US
Mailing Address - Phone:203-734-7900
Mailing Address - Fax:203-513-3269
Practice Address - Street 1:2 TRAP FALLS RD STE 404
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484-7622
Practice Address - Country:US
Practice Address - Phone:203-734-7900
Practice Address - Fax:203-513-3269
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT037651207X00000X, 207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTG78429Medicare UPIN
CT200000883Medicare ID - Type Unspecified