Healthcare Provider Details

I. General information

NPI: 1598278137
Provider Name (Legal Business Name): GREEN MOUNTAIN PLASTIC AND RECONSTRUCTIVE SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2017
Last Update Date: 11/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

354 MOUNTAIN VIEW DR STE 300
COLCHESTER VT
05446-5988
US

IV. Provider business mailing address

354 MOUNTAIN VIEW DR STE 300
COLCHESTER VT
05446-5988
US

V. Phone/Fax

Practice location:
  • Phone: 802-864-0192
  • Fax: 802-860-4919
Mailing address:
  • Phone: 802-864-0192
  • Fax: 802-860-4919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License Number42-0008887
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number42-0008887
License Number StateVT

VIII. Authorized Official

Name: DR. DONALD R LAUB JR.
Title or Position: PHYSICIAN
Credential: MD
Phone: 802-598-9619