Provider Demographics
NPI:1699899260
Name:DERCO, SCOTT L (OD)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:L
Last Name:DERCO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:188 GLEN SUMMER RD
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-5029
Mailing Address - Country:US
Mailing Address - Phone:631-472-2552
Mailing Address - Fax:
Practice Address - Street 1:2044 SUNRISE HWY
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-6018
Practice Address - Country:US
Practice Address - Phone:631-666-9595
Practice Address - Fax:631-206-1968
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYVUT-4532-1152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01964218Medicaid
NYC185DCK121Medicare PIN
NYU88459Medicare UPIN