Healthcare Provider Details

I. General information

NPI: 1053409698
Provider Name (Legal Business Name): MARK L. WULKAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 06/03/2025
Certification Date: 06/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 COLCHESTER AVE
BURLINGTON VT
05401-1473
US

IV. Provider business mailing address

111 COLCHESTER AVE
BURLINGTON VT
05401-1473
US

V. Phone/Fax

Practice location:
  • Phone: 802-847-4273
  • Fax: 802-847-4462
Mailing address:
  • Phone: 802-847-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number045676
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number35.139193
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number042.0018422
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: