Healthcare Provider Details

I. General information

NPI: 1528154713
Provider Name (Legal Business Name): MARVIN SCOTVOLD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 03/23/2021
Certification Date: 03/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 E NOB HILL BLVD
YAKIMA WA
98901-3534
US

IV. Provider business mailing address

602 E NOB HILL BLVD
YAKIMA WA
98901-3534
US

V. Phone/Fax

Practice location:
  • Phone: 509-248-3334
  • Fax: 509-453-6144
Mailing address:
  • Phone: 509-248-3334
  • Fax: 509-453-6144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD00009476
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD00009476
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: