Provider Demographics
NPI:1790824605
Name:ESTREM, SCOTT A (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:A
Last Name:ESTREM
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 1:1001 E PRIMROSE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-5155
Mailing Address - Country:US
Mailing Address - Phone:417-875-3462
Mailing Address - Fax:
Practice Address - Street 1:960 E WALNUT LAWN ST STE 102
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-7865
Practice Address - Country:US
Practice Address - Phone:417-875-3600
Practice Address - Fax:417-875-3625
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8E81207Y00000X
ARE-5863207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202141339Medicaid
AR98461OtherARK BLUE SHIELD
AR140012001Medicaid
MO132300193OtherMEDICARE PTAN
MO148764OtherMO BLUE SHIELD
MO202141339Medicaid
AR471249ZS3YMedicare PIN
AR140012001Medicaid
A02283Medicare UPIN