Healthcare Provider Details

I. General information

NPI: 1790702652
Provider Name (Legal Business Name): KIRK D SCATTERGOOD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 N 18TH AVE STE 7
STURGEON BAY WI
54235-3207
US

IV. Provider business mailing address

1035 KEPLER DR
GREEN BAY WI
54311-8320
US

V. Phone/Fax

Practice location:
  • Phone: 920-743-9532
  • Fax: 920-743-9538
Mailing address:
  • Phone: 920-490-9046
  • Fax: 920-405-8005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number36086
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number36086
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: