Provider Demographics
NPI:1164698213
Name:SCANLON, JOHN PETER (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:PETER
Last Name:SCANLON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 68356
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23471-8356
Mailing Address - Country:US
Mailing Address - Phone:757-672-1971
Mailing Address - Fax:
Practice Address - Street 1:1 COLUMBUS CTR
Practice Address - Street 2:SUITE 619
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-6722
Practice Address - Country:US
Practice Address - Phone:757-672-1971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-07
Last Update Date:2013-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY02323207QA0401X
ALDO 458207QA0401X
VA0102201920207QA0401X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64058597Medicaid
KYF66217Medicare UPIN