Provider Demographics
NPI:1184714024
Name:HACKING, SCOTT WYNN (MD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:WYNN
Last Name:HACKING
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 1:1 STILES LN
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34683-6217
Mailing Address - Country:US
Mailing Address - Phone:727-253-9449
Mailing Address - Fax:
Practice Address - Street 1:6182 GUNN HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33625-4014
Practice Address - Country:US
Practice Address - Phone:813-960-1100
Practice Address - Fax:813-960-1101
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME91368207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL277356200Medicaid