Healthcare Provider Details

I. General information

NPI: 1861756892
Provider Name (Legal Business Name): MEAD BOYKIN FERRIS III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2012
Last Update Date: 08/10/2020
Certification Date: 08/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 COLCHESTER AVE
BURLINGTON VT
05401-1473
US

IV. Provider business mailing address

15 FISHER PL
SHELBURNE VT
05482-1700
US

V. Phone/Fax

Practice location:
  • Phone: 802-847-0000
  • Fax:
Mailing address:
  • Phone: 803-434-4166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number060.0004719
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number305863
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number042.0014297
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: