Provider Demographics
NPI:1194174441
Name:HYATT, SCOTT DAVID (OD)
Entity type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:DAVID
Last Name:HYATT
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 1:1480 E LINCOLN RD
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-2128
Mailing Address - Country:US
Mailing Address - Phone:208-525-8686
Mailing Address - Fax:
Practice Address - Street 1:1480 E LINCOLN RD
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-2128
Practice Address - Country:US
Practice Address - Phone:208-525-8686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-08
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100369152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist