MEDICARE: MR. SCOTT DAVID HYATT O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	ODP-100369	ID

General Provider Information

NPI Number	:	1194174441
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SCOTT DAVID HYATT O.D.

Provider Business Mailing Address
First Line	:	1480 E LINCOLN RD
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83401-2128
Country	:	US
Telephone Number	:	208-525-8686
Fax Number	:

Provider Business Practice Location Address
First Line	:	1480 E LINCOLN RD
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83401-2128
Country	:	US
Telephone Number	:	208-525-8686
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/08/2016
Last Update Date	:	06/08/2016

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