Healthcare Provider Details

I. General information

NPI: 1932331964
Provider Name (Legal Business Name): SCOTT FOUTZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2009
Last Update Date: 03/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 UNIVERSITY BLVD NE STE C 433 PANAMERICAN FREEWAY SUITE B
ALBUQUERQUE NM
87102-1724
US

IV. Provider business mailing address

933 BRADBURY DR SE SUITE 2222
ALBUQUERQUE NM
87106-4374
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-2553
  • Fax:
Mailing address:
  • Phone: 505-272-3120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number7391914-8909
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: