Healthcare Provider Details

I. General information

NPI: 1558391243
Provider Name (Legal Business Name): MASATOSHI KIDA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
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

1 FOREST RD
ESSEX JUNCTION VT
05452-3803
US

V. Phone/Fax

Practice location:
  • Phone: 802-847-9917
  • Fax: 802-847-9644
Mailing address:
  • Phone: 802-878-1702
  • Fax: 802-878-1702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number042-0010000
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: