Provider Demographics
NPI:1720072754
Name:VANNESS, SCOTT ALLEN (DO)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:ALLEN
Last Name:VANNESS
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 1:606 MAPLE VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-1976
Mailing Address - Country:US
Mailing Address - Phone:573-756-7779
Mailing Address - Fax:573-756-6914
Practice Address - Street 1:606 MAPLE VALLEY DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-1976
Practice Address - Country:US
Practice Address - Phone:573-756-7779
Practice Address - Fax:573-756-6914
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2011-03-22
Deactivation Date:2006-03-24
Deactivation Code:
Reactivation Date:2006-04-03
Provider Licenses
StateLicense IDTaxonomies
MODO116378207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO243753613Medicaid
MO001013869Medicare PIN
MO243753613Medicaid
MO990101455Medicare PIN