Provider Demographics
NPI:1780779553
Name:HERMANN, SCOTTY ROY (MD)
Entity type:Individual
Prefix:DR
First Name:SCOTTY
Middle Name:ROY
Last Name:HERMANN
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 1:405 LONDONDERRY DR
Mailing Address - Street 2:SUITE 106
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76712-7924
Mailing Address - Country:US
Mailing Address - Phone:254-776-4961
Mailing Address - Fax:254-776-4964
Practice Address - Street 1:405 LONDONDERRY DR
Practice Address - Street 2:SUITE 106
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-7924
Practice Address - Country:US
Practice Address - Phone:254-776-4961
Practice Address - Fax:254-776-4964
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG1917207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG 1917OtherSTATE LISCENSE
TXG 1917OtherSTATE LISCENSE
B23457Medicare UPIN