Healthcare Provider Details

I. General information

NPI: 1932105467
Provider Name (Legal Business Name): MATTHEW L SCOTT O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 06/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 HWY 24 S
BUENA VISTA CO
81211-3179
US

IV. Provider business mailing address

PO BOX 3179
BUENA VISTA CO
81211-3179
US

V. Phone/Fax

Practice location:
  • Phone: 719-581-4060
  • Fax: 719-631-2577
Mailing address:
  • Phone: 719-581-4060
  • Fax: 719-631-2577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2374
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1630
License Number StateKS
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0003040
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: