=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992884456
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN GLENN SCOTT M.D., PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2006
-----------------------------------------------------
Last Update Date | 05/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2450 S TELSHOR BLVD
-----------------------------------------------------
City | LAS CRUCES
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88011-5076
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-748-9501
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22730 DIAMOND BAY DR
-----------------------------------------------------
City | FRANKSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75763-4020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-512-7704
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | MA72009
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 042-0011945
-----------------------------------------------------
License Number State | VT
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 59062
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | TM2020-1177
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------