Healthcare Provider Details

I. General information

NPI: 1427260629
Provider Name (Legal Business Name): SCOTT ANTHONY VASCONCELLOS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 10/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1004 FOWLER WAY SUITE 4
PLACERVILLE CA
95667-5746
US

IV. Provider business mailing address

1004 FOWLER WAY SUITE 4
PLACERVILLE CA
95667-5746
US

V. Phone/Fax

Practice location:
  • Phone: 530-626-9488
  • Fax: 530-626-1104
Mailing address:
  • Phone: 530-626-9488
  • Fax: 530-626-1104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberA89589
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: