Basic Information
Provider Information | |||||||||
NPI: | 1952321671 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SCOTT | ||||||||
FirstName: | JAMES | ||||||||
MiddleName: | A. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD PHD. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8 MIRROR LAKE DR | ||||||||
Address2: | STE A | ||||||||
City: | ORMOND BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 321743101 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3866732500 | ||||||||
FaxNumber: | 3866733204 | ||||||||
Practice Location | |||||||||
Address1: | 8 MIRROR LAKE DR | ||||||||
Address2: | STE A | ||||||||
City: | ORMOND BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 321743101 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3866732500 | ||||||||
FaxNumber: | 3866733204 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/19/2006 | ||||||||
LastUpdateDate: | 09/27/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | ME0058332 | FL | N |   | Other Service Providers | Specialist |   | 2084D0003X | ME058332 | FL | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Diagnostic Neuroimaging |
ID Information
ID | Type | State | Issuer | Description | 371173100 | 05 | FL |   | MEDICAID |