Basic Information
| Provider Information | |||||||||
| NPI: | 1528154713 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SCOTVOLD | ||||||||
| FirstName: | MARVIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 602 E NOB HILL BLVD | ||||||||
| Address2: | |||||||||
| City: | YAKIMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989013534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5092483334 | ||||||||
| FaxNumber: | 5094536144 | ||||||||
| Practice Location | |||||||||
| Address1: | 602 E NOB HILL BLVD | ||||||||
| Address2: | |||||||||
| City: | YAKIMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989013534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5092483334 | ||||||||
| FaxNumber: | 5094536144 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 03/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD00009476 | WA | N | Allopathic & Osteopathic Physicians | Pediatrics | 207N00000X | MD00009476 | WA | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 4963 | 01 | GROUP HEALTH | OTHER | 8372302 | 01 | WA | CHPW | OTHER | 44501 | 01 | WA | L & I | OTHER | 9390SC | 01 | WA | REGENCE | OTHER | 8372302 | 05 | WA | MEDICAID | 911019392 | 01 | COMMERCIAL | OTHER |