Provider Demographics
NPI:1679575435
Name:SCAVO, VINCENT A JR (MD)
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:A
Last Name:SCAVO
Suffix:JR
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 1:6920 POINTE INVERNESS WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7934
Mailing Address - Country:US
Mailing Address - Phone:260-479-3514
Mailing Address - Fax:260-479-3520
Practice Address - Street 1:7910 W JEFFERSON BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4159
Practice Address - Country:US
Practice Address - Phone:260-458-3555
Practice Address - Fax:260-458-3530
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01044731A208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200131210Medicaid
OH2308845Medicaid
MI4666836Medicaid
H56510Medicare UPIN
OH2308845Medicaid
IN200131210Medicaid
IN200131210Medicaid
MI4666836Medicaid
OH4085356Medicare PIN
INM400036224Medicare PIN