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General NPI Number Information
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NPI Number | 1699899260
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Entity Type | Individual
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Provider Name | SCOTT L DERCO O.D.
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Gender | Male
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Dates
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Enumeration Date | 03/19/2007
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Last Update Date | 05/01/2008
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Provider Practice Location Address
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Address Line | 2044 SUNRISE HWY
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City | BAY SHORE
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State | NY
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Zip | 11706-6018
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Country | US
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Telephone | 631-666-9595
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Fax | 631-206-1968
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Provider Business Mailing Address
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Address Line | 188 GLEN SUMMER RD
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City | HOLBROOK
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State | NY
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Zip | 11741-5029
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Country | US
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Telephone | 631-472-2552
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152WC0802X
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Taxonomy Name | Corneal and Contact Management Optometrist
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License Number | VUT-4532-1
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License Number State | NY
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