Provider Demographics
NPI:1205320991
Name:NAGAO, SCOTT MITCHELL (DO)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:MITCHELL
Last Name:NAGAO
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 1:465 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4008
Mailing Address - Country:US
Mailing Address - Phone:208-234-4700
Mailing Address - Fax:208-282-4696
Practice Address - Street 1:984 MEDICAL DR STE 1
Practice Address - Street 2:
Practice Address - City:BRIGHAM CITY
Practice Address - State:UT
Practice Address - Zip Code:84302-4712
Practice Address - Country:US
Practice Address - Phone:435-723-5248
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-18
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-1300207Q00000X
IDMRO-1737207Q00000X
UT12149108-1204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine