Provider Demographics
NPI:1558444216
Name:SAMPLE, SCOTT A (DO)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:A
Last Name:SAMPLE
Suffix:
Gender:M
Credentials:DO
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 68
Mailing Address - Street 2:
Mailing Address - City:POLLOCKSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28573-0068
Mailing Address - Country:US
Mailing Address - Phone:252-635-6777
Mailing Address - Fax:252-634-3183
Practice Address - Street 1:1001 NEWMAN RD
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28562-5253
Practice Address - Country:US
Practice Address - Phone:252-635-6777
Practice Address - Fax:252-634-3183
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMED-PHYS-LIC-10527207RI0011X
NC2020-00954207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0072607OtherMDCD PIN
MT000096785OtherBCBS PIN
WY119419400OtherMDCD PIN
WYW20331Medicare PIN
MT0072607OtherMDCD PIN
MT000096785OtherBCBS PIN
WY119419400OtherMDCD PIN
MT000083955Medicare PIN