Healthcare Provider Details

I. General information

NPI: 1740262427
Provider Name (Legal Business Name): SCOTT EUGENE DESJARLAIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 08/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

980 HIGHWAY 28 SUITE 100
JASPER TN
37347-3695
US

IV. Provider business mailing address

980 HIGHWAY 28 SUITE 100
JASPER TN
37347-3695
US

V. Phone/Fax

Practice location:
  • Phone: 423-942-1602
  • Fax: 423-942-1265
Mailing address:
  • Phone: 423-942-1602
  • Fax: 423-942-1265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD25036
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: