Basic Information
| Provider Information | |||||||||
| NPI: | 1275580599 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VAN POPPEL | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3255 E ELWOOD ST | ||||||||
| Address2: | #110 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850347256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024705043 | ||||||||
| FaxNumber: | 6024705064 | ||||||||
| Practice Location | |||||||||
| Address1: | 2601 E ROOSEVELT ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850084973 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023445892 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2006 | ||||||||
| LastUpdateDate: | 05/10/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 33845 | AZ | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | N6079 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00898581 | 01 | TX | RAILROAD | OTHER | 214057601 | 05 | TX | MEDICAID | 214057602 | 05 | TX | MEDICAID |