Provider Demographics
NPI:1780641464
Name:SCOTT, WALTER PHELPS (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:PHELPS
Last Name:SCOTT
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 19675
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32245-9675
Mailing Address - Country:US
Mailing Address - Phone:904-346-3338
Mailing Address - Fax:904-346-0815
Practice Address - Street 1:1375 ROBERTS DR
Practice Address - Street 2:SUITE 100
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-3210
Practice Address - Country:US
Practice Address - Phone:904-242-0166
Practice Address - Fax:904-242-0167
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME7190174400000X, 2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL15395OtherBCBS
FL039593500Medicaid
FL223010OtherAVMED
FLP00240199OtherMEDICARE RAILROAD
FL15395QMedicare PIN
FL15395TMedicare PIN
FL15395KMedicare PIN
FL15395OMedicare PIN
FL15395IMedicare PIN
FL15395SMedicare PIN
FL039593500Medicaid
FL15395LMedicare PIN
FL15395NMedicare PIN
FL15395RMedicare PIN
FL15395HMedicare PIN
FLD52558Medicare UPIN
FL15395JMedicare PIN
FL15395PMedicare PIN