Healthcare Provider Details

I. General information

NPI: 1093749756
Provider Name (Legal Business Name): MARTIN R LULOFF M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 10/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 HOSPITAL DR SUITE 207
BENNINGTON VT
05201-5009
US

IV. Provider business mailing address

74 GORDONS WAY
ARLINGTON VT
05250
US

V. Phone/Fax

Practice location:
  • Phone: 802-447-3930
  • Fax: 802-447-8539
Mailing address:
  • Phone: 508-435-5506
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number43877
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: