Provider Demographics
NPI:1871599548
Name:SCOTT, THEODORE DAVID (RN, MSN, FNP-C, DCNP)
Entity type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:DAVID
Last Name:SCOTT
Suffix:
Gender:M
Credentials:RN, MSN, FNP-C, DCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:400 CRAVEN ROAD
Mailing Address - Street 2:DEPARTMENT OF DERMATOLOGY
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92079-4201
Mailing Address - Country:US
Mailing Address - Phone:760-510-4056
Mailing Address - Fax:760-510-4201
Practice Address - Street 1:400 CRAVEN ROAD
Practice Address - Street 2:DEPARTMENT OF DERMATOLOGY
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92078-4201
Practice Address - Country:US
Practice Address - Phone:760-510-4056
Practice Address - Fax:760-510-4212
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CARN 495518363LF0000X
CANP 9406363LF0000X
CANP9406363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP66844Medicare UPIN