Provider Demographics
NPI:1790892644
Name:VAN GORDER, SCOTT C (DO)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:C
Last Name:VAN GORDER
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 1:61 DELANO ST
Mailing Address - Street 2:
Mailing Address - City:PULASKI
Mailing Address - State:NY
Mailing Address - Zip Code:13142-1400
Mailing Address - Country:US
Mailing Address - Phone:315-298-6564
Mailing Address - Fax:315-298-7831
Practice Address - Street 1:10 GEORGE ST
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-3276
Practice Address - Country:US
Practice Address - Phone:315-342-0888
Practice Address - Fax:315-343-4663
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY213595207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02081198Medicaid
NYH13108Medicare UPIN
NYBB9996Medicare ID - Type Unspecified