Provider Demographics
NPI:1235242611
Name:VANDIVER, SCOTT L (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:L
Last Name:VANDIVER
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 1:562 WINDWOOD LN
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-7089
Mailing Address - Country:US
Mailing Address - Phone:828-963-3867
Mailing Address - Fax:
Practice Address - Street 1:895 STATE FARM RD STE 401
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-4917
Practice Address - Country:US
Practice Address - Phone:828-264-4691
Practice Address - Fax:828-265-4288
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC28584207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8984686Medicaid
NC2187066Medicare ID - Type Unspecified
NC8984686Medicaid