Provider Demographics
NPI:1942804760
Name:DUFOUR, SCOTT GREGORY
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:GREGORY
Last Name:DUFOUR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5832 OGDEN AVE
Mailing Address - Street 2:
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44004-7448
Mailing Address - Country:US
Mailing Address - Phone:440-661-1663
Mailing Address - Fax:
Practice Address - Street 1:5832 OGDEN AVE
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-7448
Practice Address - Country:US
Practice Address - Phone:440-661-1663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0402415Medicaid