Healthcare Provider Details

I. General information

NPI: 1780674655
Provider Name (Legal Business Name): FRED DACON SCOTT DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 09/01/2020
Certification Date: 09/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 N ALLEN ST
ROBINSON IL
62454-1167
US

IV. Provider business mailing address

1000 N ALLEN ST
ROBINSON IL
62454-1167
US

V. Phone/Fax

Practice location:
  • Phone: 618-546-2618
  • Fax: 618-546-2669
Mailing address:
  • Phone: 618-546-2618
  • Fax: 618-546-2669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036090368
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: