Provider Demographics
NPI:1528035136
Name:DERON, SCOTT JOHN (DO)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:JOHN
Last Name:DERON
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 1:21 PRIMROSE PL
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-5891
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21 PRIMROSE PL
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-5891
Practice Address - Country:US
Practice Address - Phone:207-989-1054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS005372L207RB0002X, 207RC0000X, 207RI0011X
MEDO2065207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RB0002XAllopathic & Osteopathic PhysiciansInternal MedicineObesity Medicine
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0009784500006Medicaid
PA0009784500006Medicaid
PAB40510Medicare UPIN