Healthcare Provider Details

I. General information

NPI: 1902825201
Provider Name (Legal Business Name): RICHARD WASSERMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 S PROSPECT ST
BURLINGTON VT
05401-3456
US

IV. Provider business mailing address

1 S PROSPECT ST ARNOLD 5455
BURLINGTON VT
05401-3456
US

V. Phone/Fax

Practice location:
  • Phone: 802-847-4544
  • Fax: 802-847-4612
Mailing address:
  • Phone: 802-847-4611
  • Fax: 802-847-8170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number42-6028
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: