Healthcare Provider Details

I. General information

NPI: 1366606055
Provider Name (Legal Business Name): CHANTAL JOSEE BOISVERT OD, MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2008
Last Update Date: 10/04/2023
Certification Date: 10/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 COLCHESTER AVE
BURLINGTON VT
05401-1473
US

IV. Provider business mailing address

2351 ERWIN RD
DURHAM NC
27705-4699
US

V. Phone/Fax

Practice location:
  • Phone: 802-847-0400
  • Fax:
Mailing address:
  • Phone: 919-681-9191
  • Fax: 199-684-0547

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number042-0017057
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberA104628
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207WX0109X
TaxonomyNeuro-ophthalmology Physician
License NumberA104628
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207WX0109X
TaxonomyNeuro-ophthalmology Physician
License Number2019-01326
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code207WX0110X
TaxonomyPediatric Ophthalmology and Strabismus Specialist Physician Physician
License NumberA104628
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: