Healthcare Provider Details

I. General information

NPI: 1871599548
Provider Name (Legal Business Name): THEODORE DAVID SCOTT RN, MSN, FNP-C, DCNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 04/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 CRAVEN ROAD DEPARTMENT OF DERMATOLOGY
SAN MARCOS CA
92078-4201
US

IV. Provider business mailing address

400 CRAVEN ROAD DEPARTMENT OF DERMATOLOGY
SAN MARCOS CA
92079-4201
US

V. Phone/Fax

Practice location:
  • Phone: 760-510-4056
  • Fax: 760-510-4212
Mailing address:
  • Phone: 760-510-4056
  • Fax: 760-510-4201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN 495518
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP 9406
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNP9406
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: