Provider Demographics
NPI:1982780433
Name:SURDUT, SCOTT H (OD)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:H
Last Name:SURDUT
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 1:1013 RESERVOIR AVE
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02910-5134
Mailing Address - Country:US
Mailing Address - Phone:401-942-4087
Mailing Address - Fax:
Practice Address - Street 1:1013 RESERVOIR AVE
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02910-5134
Practice Address - Country:US
Practice Address - Phone:401-942-4087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIODTA 00356152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI050381140OtherTAX #
RI007002604Medicare ID - Type Unspecified
RIT79234Medicare UPIN
RI0219570001Medicare NSC