Provider Demographics
NPI:1609854835
Name:BURGESS, SCOTT VASSAR (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:VASSAR
Last Name:BURGESS
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 1:856 J CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:120 KINGS WAY
Practice Address - Street 2:SUITE 3200
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185-2505
Practice Address - Country:US
Practice Address - Phone:757-253-0051
Practice Address - Fax:757-229-9526
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101238311208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1609854835Medicaid
VAP00397272Medicare PIN
VAI17846Medicare UPIN
VA1609854835Medicaid