Provider Demographics
NPI:1992884456
Name:SCOTT, JOHN GLENN (MD, PHD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:GLENN
Last Name:SCOTT
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22730 DIAMOND BAY DR
Mailing Address - Street 2:
Mailing Address - City:FRANKSTON
Mailing Address - State:TX
Mailing Address - Zip Code:75763-4020
Mailing Address - Country:US
Mailing Address - Phone:732-512-7704
Mailing Address - Fax:
Practice Address - Street 1:2450 S TELSHOR BLVD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-5076
Practice Address - Country:US
Practice Address - Phone:802-748-9501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA72009207Q00000X
VT042-0011945207Q00000X
TX59062207Q00000X
NMTM2020-1177207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8975604Medicaid
NH3075635Medicaid
VT1017399Medicaid
NJ065918A02Medicare PIN
NJDO9000Medicare UPIN
NJ8975604Medicaid