=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174649412
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SCOTT WILLIAM VANLUE MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2007
-----------------------------------------------------
Last Update Date | 04/15/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 940 CENTRE CIR SUITE 1010
-----------------------------------------------------
City | ALTAMONTE SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32714-7604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-862-5637
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1208 DUNLAWTON AVE
-----------------------------------------------------
City | PORT ORANGE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32127-4746
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-862-5637
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | ME51026
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------