Basic Information
| Provider Information | |||||||||
| NPI: | 1619138658 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCOTT | ||||||||
| FirstName: | RANDALL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3189 HIGHWAY 17 | ||||||||
| Address2: | |||||||||
| City: | GREEN COVE SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320439371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046210247 | ||||||||
| FaxNumber: | 9043399945 | ||||||||
| Practice Location | |||||||||
| Address1: | 3189 HIGHWAY 17 | ||||||||
| Address2: | |||||||||
| City: | GREEN COVE SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320439371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046210643 | ||||||||
| FaxNumber: | 9046210644 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2008 | ||||||||
| LastUpdateDate: | 09/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | OS 11177 | FL | N | Allopathic & Osteopathic Physicians | General Practice | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | OS11177 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.