Provider Demographics
NPI:1316059728
Name:POUYAT, SCOTT D (OD)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:D
Last Name:POUYAT
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 1:534 N RAND RD
Mailing Address - Street 2:C/O LAKE ZURICH EYECARE
Mailing Address - City:LAKE ZURICH
Mailing Address - State:IL
Mailing Address - Zip Code:60047-3103
Mailing Address - Country:US
Mailing Address - Phone:847-997-1477
Mailing Address - Fax:
Practice Address - Street 1:534 N RAND RD
Practice Address - Street 2:C/O LAKE ZURICH EYECARE
Practice Address - City:LAKE ZURICH
Practice Address - State:IL
Practice Address - Zip Code:60047-3103
Practice Address - Country:US
Practice Address - Phone:847-550-5228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2010-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL46009065152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU68470Medicare UPIN
IL200199Medicare PIN