Provider Demographics
NPI:1457702920
Name:SAMPLE, SCOTT DAVID (MASTERS OF ARTS)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:DAVID
Last Name:SAMPLE
Suffix:
Gender:M
Credentials:MASTERS OF ARTS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22111 GRIX ST
Mailing Address - Street 2:
Mailing Address - City:WOODHAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:48183-3247
Mailing Address - Country:US
Mailing Address - Phone:734-558-4217
Mailing Address - Fax:
Practice Address - Street 1:22111 GRIX ST
Practice Address - Street 2:
Practice Address - City:WOODHAVEN
Practice Address - State:MI
Practice Address - Zip Code:48183-3247
Practice Address - Country:US
Practice Address - Phone:734-558-4217
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-27
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other