Provider Demographics
NPI:1245332782
Name:SCOTT-JOHNSTON, VANDA R (DPM)
Entity type:Individual
Prefix:DR
First Name:VANDA
Middle Name:R
Last Name:SCOTT-JOHNSTON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13445 166TH PL
Mailing Address - Street 2:APT# 12B
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434-3854
Mailing Address - Country:US
Mailing Address - Phone:718-712-7496
Mailing Address - Fax:
Practice Address - Street 1:241 W 138TH ST
Practice Address - Street 2:GROUND FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10030-2102
Practice Address - Country:US
Practice Address - Phone:212-694-2392
Practice Address - Fax:212-694-4020
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004013213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0012137OtherG.H.I.
NY00913144Medicaid
NY00913144Medicaid
NYP41271Medicare ID - Type Unspecified