Healthcare Provider Details

I. General information

NPI: 1861892135
Provider Name (Legal Business Name): MAURY SCOTT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2014
Last Update Date: 08/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W ARBOR DR
SAN DIEGO CA
92103-9000
US

IV. Provider business mailing address

5718 58TH PL
SAN DIEGO CA
92115-6117
US

V. Phone/Fax

Practice location:
  • Phone: 619-543-6502
  • Fax:
Mailing address:
  • Phone: 619-865-2403
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number500425
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number500425
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: