Healthcare Provider Details

I. General information

NPI: 1386344331
Provider Name (Legal Business Name): MARTHAS VINEYARD EAR NOSE AND THROAT SPECIALISTS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2023
Last Update Date: 03/08/2023
Certification Date: 03/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 INDIAN HILL RD
WEST TISBURY MA
02575
US

IV. Provider business mailing address

60 MEETING HOUSE RD
CHILMARK MA
02535-2517
US

V. Phone/Fax

Practice location:
  • Phone: 508-367-7131
  • Fax:
Mailing address:
  • Phone: 508-648-9468
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YS0012X
TaxonomySleep Medicine (Otolaryngology) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: EDWARD CALDWELL
Title or Position: PRESIDENT
Credential: MD
Phone: 508-648-9468