Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081P2900X | Pain Medicine | OS 9769 | FL |
NPI | 1215966577 |
---|---|
Provider Name | Scott Forrest Corneal |
First Address | St Augustine, FL 32080-3108 |
Second Address | St Augustine, FL 32080-3108 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/06/2006 |
Last Update Date | 17/03/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
BC8485117 | DEA NUMBER (01) | |
H93993 | (02) |