Healthcare Provider Details

I. General information

NPI: 1245619873
Provider Name (Legal Business Name): SCOTT HUSSEY OD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2015
Last Update Date: 01/27/2020
Certification Date: 01/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

532 OLD SMIZER MILL RD
FENTON MO
63026-3538
US

IV. Provider business mailing address

480 OLD SMIZER MILL RD
FENTON MO
63026-3553
US

V. Phone/Fax

Practice location:
  • Phone: 636-305-7110
  • Fax:
Mailing address:
  • Phone: 636-305-7110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2003014776
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number StateMO

VIII. Authorized Official

Name: DR. SCOTT T HUSSEY
Title or Position: OWNER
Credential: O.D.
Phone: 636-305-7110