MEDICARE: DR. JEFFREY SCOTT O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	046011029	IL
2	152W00000X	Optometrist	OPT34978TLG	CA

General Provider Information

NPI Number	:	1568813434
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFREY SCOTT O.D.

Provider Business Mailing Address
First Line	:	820 E TERRA COTTA AVE STE 256
Second Line	:
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60014-3655
Country	:	US
Telephone Number	:	815-455-2800
Fax Number	:

Provider Business Practice Location Address
First Line	:	1403 N TUSTIN AVE STE 399
Second Line	:
City	:	SANTA ANA
State	:	CA
Zip	:	92705-8691
Country	:	US
Telephone Number	:	714-884-3961
Fax Number	:	714-884-3458

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/22/2016
Last Update Date	:	11/12/2021

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