=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992794200
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SCOTT LESLIE VANDEVORDE DPM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8957 OTTOGAN ST
-----------------------------------------------------
City | HOLLAND
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49423-9044
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-748-9025
-----------------------------------------------------
Fax | 616-748-9124
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 430 E 8TH ST PMB 182
-----------------------------------------------------
City | HOLLAND
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49423-3751
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-748-9025
-----------------------------------------------------
Fax | 616-748-9124
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | SV001569
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | 5901001567
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------