Provider Demographics
NPI:1750360137
Name:SCOTT, CLINTON HERWIN JR (DPM)
Entity type:Individual
Prefix:DR
First Name:CLINTON
Middle Name:HERWIN
Last Name:SCOTT
Suffix:JR
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3903 PORTAGE RD
Mailing Address - Street 2:SUITE C #161
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46628-4431
Mailing Address - Country:US
Mailing Address - Phone:609-440-8714
Mailing Address - Fax:
Practice Address - Street 1:3903 PORTAGE RD
Practice Address - Street 2:SUITE C # 161
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46628-4431
Practice Address - Country:US
Practice Address - Phone:609-440-8714
Practice Address - Fax:269-469-9240
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-12
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07000990A213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000339432OtherANTHEM
IN200305000Medicaid
INP00158243Medicare PIN
INV01620Medicare UPIN
IN200305000Medicaid