Healthcare Provider Details

I. General information

NPI: 1659402485
Provider Name (Legal Business Name): WARREN MARK PELUSO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PARTON HC MIDDLEBURY COLLEGE 5110
MIDDLEBURY VT
05753
US

IV. Provider business mailing address

PARTON HC MIDDLEBURY COLLEGE 5110
MIDDLEBURY VT
05753
US

V. Phone/Fax

Practice location:
  • Phone: 804-443-5135
  • Fax: 802-443-2066
Mailing address:
  • Phone: 804-443-5135
  • Fax: 802-443-2066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number042-0010097
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: