Healthcare Provider Details

I. General information

NPI: 1194830083
Provider Name (Legal Business Name): BONITA SANDRA LIBMAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 10/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 COLCHESTER AVE EAST PAVILION LEVEL 5 RHEUMATOLOGY
BURLINGTON VT
05401-1473
US

IV. Provider business mailing address

111 COLCHESTER AVE
BURLINGTON VT
05401-1473
US

V. Phone/Fax

Practice location:
  • Phone: 802-847-4574
  • Fax: 802-847-9695
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number0420008785
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: