Basic Information
| Provider Information | |||||||||
| NPI: | 1083123400 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SCOTT SMALL, D.O., INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8320 RESIDENCIA | ||||||||
| Address2: | |||||||||
| City: | NEWPORT BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926609063 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166590544 | ||||||||
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| Practice Location | |||||||||
| Address1: | 17251 17TH ST | ||||||||
| Address2: | |||||||||
| City: | TUSTIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927801970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148322273 | ||||||||
| FaxNumber: | 7148322272 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2017 | ||||||||
| LastUpdateDate: | 09/28/2017 | ||||||||
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| AuthorizedOfficialLastName: | SMALL | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5166590544 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | 20A11607 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 20A11607 | 01 | CA | MEDICAL LICENSE | OTHER |