Provider Demographics
NPI:1396463279
Name:SCOTT, JOHN PHILLIP
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:PHILLIP
Last Name:SCOTT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 MERRITT ST
Mailing Address - Street 2:
Mailing Address - City:RIVER OAKS
Mailing Address - State:TX
Mailing Address - Zip Code:76114-2939
Mailing Address - Country:US
Mailing Address - Phone:817-525-0560
Mailing Address - Fax:
Practice Address - Street 1:7377 WASHINGTON BLVD BLDG STE 101
Practice Address - Street 2:
Practice Address - City:ELKRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21075-6360
Practice Address - Country:US
Practice Address - Phone:410-379-3051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-17
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX591466156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156F00000XEye and Vision Services ProvidersTechnician/TechnologistGroup - Single Specialty