Healthcare Provider Details

I. General information

NPI: 1770224792
Provider Name (Legal Business Name): MICHAEL ANDREW SCOTT DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 08/11/2025
Certification Date: 08/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 E RIVERSIDE DR
EAGLE ID
83616-6864
US

IV. Provider business mailing address

1601 CUMMINS DR STE D
MODESTO CA
95358-6411
US

V. Phone/Fax

Practice location:
  • Phone: 208-367-5300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberDO224369
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number9671256
License Number StateID
# 4
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberV3103
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: