Provider Demographics
NPI:1215966577
Name:CORNEAL, SCOTT FORREST (DO)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:FORREST
Last Name:CORNEAL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1301 PLANTATION ISLAND DR S
Mailing Address - Street 2:SUITE 402A
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-3108
Mailing Address - Country:US
Mailing Address - Phone:904-471-4744
Mailing Address - Fax:904-471-4745
Practice Address - Street 1:1301 PLANTATION ISLAND DR S
Practice Address - Street 2:SUITE 402A
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-3108
Practice Address - Country:US
Practice Address - Phone:904-471-4744
Practice Address - Fax:904-471-4745
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS 97692081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
BC8485117OtherDEA NUMBER
BC8485117OtherDEA NUMBER
GA25BBFVPMedicare ID - Type Unspecified