Provider Demographics
NPI:1093809188
Name:MACDONALD, ROBERT SCOTT (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:SCOTT
Last Name:MACDONALD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 LONGVIEW ST
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-4516
Mailing Address - Country:US
Mailing Address - Phone:423-245-5289
Mailing Address - Fax:
Practice Address - Street 1:914 BROAD ST
Practice Address - Street 2:SUITE 3A
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3817
Practice Address - Country:US
Practice Address - Phone:423-247-5553
Practice Address - Fax:423-247-9254
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD00000149422084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3000957Medicaid
TN0023714OtherBLUE CROSS/BLUE SHIELD
VA6101372Medicaid
TN3000959Medicare ID - Type Unspecified
TN0023714OtherBLUE CROSS/BLUE SHIELD