Healthcare Provider Details

I. General information

NPI: 1073598330
Provider Name (Legal Business Name): JON SCOTT ULOTH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 08/18/2020
Certification Date: 08/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3711 CASEY RD
NEWBURGH IN
47630-8343
US

IV. Provider business mailing address

PO BOX 1510
EVANSVILLE IN
47706-1510
US

V. Phone/Fax

Practice location:
  • Phone: 812-490-1122
  • Fax: 812-490-1123
Mailing address:
  • Phone: 812-435-0977
  • Fax: 812-450-6288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number51751
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01041620
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: