Healthcare Provider Details

I. General information

NPI: 1114181435
Provider Name (Legal Business Name): SCOTT M VANVALKENBURG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2008
Last Update Date: 09/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6620 FLY RD STE 200
EAST SYRACUSE NY
13057-9791
US

IV. Provider business mailing address

6620 FLY ROAD STE 200
E. SYRACUSE NY
13057
US

V. Phone/Fax

Practice location:
  • Phone: 315-464-4472
  • Fax: 315-464-5229
Mailing address:
  • Phone: 315-464-4472
  • Fax: 315-464-5229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number14250
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number274789
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License Number274789
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: