Provider Demographics
NPI:1831185867
Name:SCOTT, ROGER W JR (OD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:W
Last Name:SCOTT
Suffix:JR
Gender:M
Credentials:OD
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Mailing Address - Street 1:4075 MARIETTA HWY
Mailing Address - Street 2:110
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30157-3315
Mailing Address - Country:US
Mailing Address - Phone:770-445-9866
Mailing Address - Fax:770-445-8244
Practice Address - Street 1:4075 MARIETTA HWY
Practice Address - Street 2:110
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30157-3315
Practice Address - Country:US
Practice Address - Phone:770-445-9866
Practice Address - Fax:770-445-8244
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-26
Last Update Date:2015-01-06
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Provider Licenses
StateLicense IDTaxonomies
GA1253152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000521881AMedicaid
GAU06203Medicare UPIN
GA000521881AMedicaid