Provider Demographics
NPI:1285637082
Name:POWELL, SCOTT J (MD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:J
Last Name:POWELL
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:PO BOX 9477
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75711-9477
Mailing Address - Country:US
Mailing Address - Phone:903-594-2450
Mailing Address - Fax:903-594-2450
Practice Address - Street 1:1725 S INTERSTATE 35 E STE 101
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76205-6603
Practice Address - Country:US
Practice Address - Phone:940-808-0949
Practice Address - Fax:903-438-2197
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL8897208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX168090202Medicaid
TXP00282718OtherRAILROAD MEDICARE
TX168090201Medicaid
TX8S6184OtherBLUE CROSS
TX8G0550Medicare PIN
TXP00282718OtherRAILROAD MEDICARE