Provider Demographics
NPI:1689676231
Name:SCOLES, LYNDELL D (MD)
Entity type:Individual
Prefix:
First Name:LYNDELL
Middle Name:D
Last Name:SCOLES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1605 E BROADWAY
Mailing Address - Street 2:STE 280
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-8023
Mailing Address - Country:US
Mailing Address - Phone:573-815-8155
Mailing Address - Fax:573-815-8154
Practice Address - Street 1:1605 E BROADWAY
Practice Address - Street 2:STE 280
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-8023
Practice Address - Country:US
Practice Address - Phone:573-815-8155
Practice Address - Fax:573-815-8154
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-12
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6P51207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203726922Medicaid
MO203726922Medicaid
MO0010113928Medicare ID - Type Unspecified