Healthcare Provider Details

I. General information

NPI: 1639203169
Provider Name (Legal Business Name): SCOTT ROBERT WITHERSPOON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 07/23/2024
Certification Date: 07/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3414 OAK GROVE AVE
DALLAS TX
75204-2375
US

IV. Provider business mailing address

3414 OAK GROVE AVE
DALLAS TX
75204-2375
US

V. Phone/Fax

Practice location:
  • Phone: 214-521-1153
  • Fax: 214-219-3651
Mailing address:
  • Phone: 214-521-1153
  • Fax: 214-219-3651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberN2885
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License NumberN2885
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: