Healthcare Provider Details

I. General information

NPI: 1679595094
Provider Name (Legal Business Name): MARCUS BOSENBERG M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 COLCHESTER AVE
BURLINGTON VT
05401-1473
US

IV. Provider business mailing address

460 MARTEL LN
ST GEORGE VT
05495-7087
US

V. Phone/Fax

Practice location:
  • Phone: 802-847-9447
  • Fax: 802-847-9644
Mailing address:
  • Phone: 802-878-0917
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number042-0010348
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: