Healthcare Provider Details

I. General information

NPI: 1043238017
Provider Name (Legal Business Name): DAVID NIELSEN KRAG MD
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

111 COLCHESTER AVE MAIN PAVILIION-LEVEL 2
BURLINGTON VT
05401-1473
US

IV. Provider business mailing address

76 RIVERVALE RD
SHELBURNE VT
05482-4415
US

V. Phone/Fax

Practice location:
  • Phone: 802-656-5830
  • Fax: 802-656-5833
Mailing address:
  • Phone: 802-656-5830
  • Fax: 802-656-5833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number042-0008329
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: