Provider Demographics
NPI:1104084326
Name:MIMMS, SCOTT EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:EDWARD
Last Name:MIMMS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:1704 LAFAYETTE RD STE 5
Practice Address - Street 2:
Practice Address - City:CRAWFORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47933
Practice Address - Country:US
Practice Address - Phone:765-361-3011
Practice Address - Fax:765-362-5540
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-23
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01068514A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000781470OtherANTHEM
IN200986830Medicaid
IN200986830Medicaid
IN000000781470OtherANTHEM