Healthcare Provider Details

I. General information

NPI: 1578664835
Provider Name (Legal Business Name): SCOT LEBOLT M.D,
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 03/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8001 FORBES PL SUITE 103
SPRINGFIELD VA
22151-2208
US

IV. Provider business mailing address

PO BOX 79537
BALTIMORE MD
21279-0537
US

V. Phone/Fax

Practice location:
  • Phone: 703-824-3200
  • Fax:
Mailing address:
  • Phone: 703-824-3200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0101038652
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: