Provider Demographics
NPI:1285966317
Name:MIST, SCOTT DAVID (MACOM, PHD)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:DAVID
Last Name:MIST
Suffix:
Gender:
Credentials:MACOM, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4116 SE OAK ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-2032
Mailing Address - Country:US
Mailing Address - Phone:971-998-3505
Mailing Address - Fax:
Practice Address - Street 1:3705 SE CESAR CHAVEZ BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-1704
Practice Address - Country:US
Practice Address - Phone:971-420-3245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-29
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OROR00779171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist