Provider Demographics
NPI:1699719708
Name:BOURNS, SCOTT GEORGE (DO)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:GEORGE
Last Name:BOURNS
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 3067
Mailing Address - Street 2:
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92244-3067
Mailing Address - Country:US
Mailing Address - Phone:734-883-5662
Mailing Address - Fax:
Practice Address - Street 1:223 W COLE BLVD
Practice Address - Street 2:
Practice Address - City:CALEXICO
Practice Address - State:CA
Practice Address - Zip Code:92231-9722
Practice Address - Country:US
Practice Address - Phone:734-883-5662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2011-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A 9042207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H23011Medicare UPIN