Provider Demographics
NPI:1780674655
Name:SCOTT, FRED DACON (DO)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:DACON
Last Name:SCOTT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 N ALLEN ST
Mailing Address - Street 2:
Mailing Address - City:ROBINSON
Mailing Address - State:IL
Mailing Address - Zip Code:62454-1167
Mailing Address - Country:US
Mailing Address - Phone:618-546-2618
Mailing Address - Fax:618-546-2669
Practice Address - Street 1:1000 N ALLEN ST
Practice Address - Street 2:
Practice Address - City:ROBINSON
Practice Address - State:IL
Practice Address - Zip Code:62454-1167
Practice Address - Country:US
Practice Address - Phone:618-546-2618
Practice Address - Fax:618-546-2669
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036090368208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036090368Medicaid
ILL76491Medicare ID - Type Unspecified
IL036090368Medicaid