Provider Demographics
NPI:1104880657
Name:SELLER, SCOTT EVAN (OD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:EVAN
Last Name:SELLER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 RIDGEWAY ST
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71901-7102
Mailing Address - Country:US
Mailing Address - Phone:501-321-2473
Mailing Address - Fax:
Practice Address - Street 1:103 RIDGEWAY ST
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71901-7102
Practice Address - Country:US
Practice Address - Phone:501-321-2473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-13
Last Update Date:2011-05-26
Deactivation Date:2007-12-03
Deactivation Code:
Reactivation Date:2007-12-10
Provider Licenses
StateLicense IDTaxonomies
AR2286152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR49282G846OtherGROUP MEMBER PTAN
AR102427722Medicaid
AR49282G846OtherGROUP MEMBER PTAN
ART20298Medicare UPIN