Provider Demographics
NPI:1881699205
Name:BOUGHTON, R SCOTT (MD)
Entity type:Individual
Prefix:DR
First Name:R
Middle Name:SCOTT
Last Name:BOUGHTON
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 1:7300 GIRARD AVE
Mailing Address - Street 2:STE 202
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-5138
Mailing Address - Country:US
Mailing Address - Phone:858-454-7123
Mailing Address - Fax:858-454-5724
Practice Address - Street 1:7300 GIRARD AVE
Practice Address - Street 2:STE 202
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-5138
Practice Address - Country:US
Practice Address - Phone:858-454-7123
Practice Address - Fax:858-454-5724
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-14
Last Update Date:2007-07-08
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-23
Provider Licenses
StateLicense IDTaxonomies
CAG037646174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG37646Medicare ID - Type Unspecified
CAA91918Medicare UPIN