Provider Demographics
NPI:1780864678
Name:BACKUS, SCOTT R (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:R
Last Name:BACKUS
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 1:6111 EXECUTIVE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-3911
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6111 EXECUTIVE BLVD
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-3911
Practice Address - Country:US
Practice Address - Phone:301-255-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-07
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101247623207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1780864678Medicaid
NCPENDINGMedicaid
VAPENDINGMedicare PIN