Provider Demographics
NPI:1114181435
Name:VANVALKENBURG, SCOTT M (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:M
Last Name:VANVALKENBURG
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 1:6620 FLY ROAD
Mailing Address - Street 2:STE 200
Mailing Address - City:E. SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057
Mailing Address - Country:US
Mailing Address - Phone:315-464-4472
Mailing Address - Fax:315-464-5229
Practice Address - Street 1:6620 FLY RD
Practice Address - Street 2:STE 200
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-9791
Practice Address - Country:US
Practice Address - Phone:315-464-4472
Practice Address - Fax:315-464-5229
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-16
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI14250207X00000X
NY274789207X00000X, 207XX0004X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program