Healthcare Provider Details

I. General information

NPI: 1255472916
Provider Name (Legal Business Name): SCOTT BAYLARD O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 03/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2320 ATLANTA HWY SUITE 103
CUMMING GA
30040-6339
US

IV. Provider business mailing address

2320 ATLANTA HIGHWAY SUITE 103
CUMMING GA
30040
US

V. Phone/Fax

Practice location:
  • Phone: 678-965-5558
  • Fax:
Mailing address:
  • Phone: 678-965-5558
  • Fax: 678-965-5502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2005
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: