Healthcare Provider Details

I. General information

NPI: 1750373882
Provider Name (Legal Business Name): SUDHIN KANABAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 01/20/2023
Certification Date: 01/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 FISHER RD
BERLIN VT
05602-9516
US

IV. Provider business mailing address

130 FISHER RD
BERLIN VT
05602-9516
US

V. Phone/Fax

Practice location:
  • Phone: 802-371-4100
  • Fax: 513-793-1032
Mailing address:
  • Phone: 802-371-4100
  • Fax: 513-793-1032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number35-077505 K
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number042.0016633
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: