Provider Demographics
NPI:1053495226
Name:STANDAGE, SCOTT JEFFREY (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:JEFFREY
Last Name:STANDAGE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:751 S BASCOM AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-2604
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:751 S BASCOM AVE
Practice Address - Street 2:P.M &R
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-2604
Practice Address - Country:US
Practice Address - Phone:408-885-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA69332208100000X, 2081P0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081P0004XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSpinal Cord Injury Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH69023Medicare UPIN
CA00A693320Medicare PIN