Provider Demographics
NPI:1013945070
Name:CHENNAULT, JOHN SCOTT (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:SCOTT
Last Name:CHENNAULT
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:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:254-724-8800
Mailing Address - Fax:
Practice Address - Street 1:1010 WOODSON DR
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:TX
Practice Address - Zip Code:77836-1000
Practice Address - Country:US
Practice Address - Phone:979-567-4900
Practice Address - Fax:979-567-4901
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH4233207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXDU4497OtherMEDICARE GROUP PTAN
TXP000D29E6Medicaid
TXP01278536OtherPROVIDER PTAN
TXD79EMedicare ID - Type Unspecified
TX00D79EMedicare UPIN
TXD86907Medicare UPIN
TXP000D29E6Medicaid