Provider Demographics
NPI:1992794200
Name:VANDEVORDE, SCOTT LESLIE (DPM)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:LESLIE
Last Name:VANDEVORDE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 E 8TH ST
Mailing Address - Street 2:PMB 182
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-3751
Mailing Address - Country:US
Mailing Address - Phone:616-748-9025
Mailing Address - Fax:616-748-9124
Practice Address - Street 1:8957 OTTOGAN ST
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-9044
Practice Address - Country:US
Practice Address - Phone:616-748-9025
Practice Address - Fax:616-748-9124
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISV001569213E00000X
MI5901001567213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4857059590OtherBCBS
U21866Medicare UPIN
MI2773407Medicare ID - Type Unspecified
5705959Medicare ID - Type Unspecified