Healthcare Provider Details

I. General information

NPI: 1487628608
Provider Name (Legal Business Name): THOMAS G BOLDUC M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 03/22/2021
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 HAYDENBERRY DR UNIT 103
MILTON VT
05468-2200
US

IV. Provider business mailing address

66 KNIGHT LN STE 10
WILLISTON VT
05495-9308
US

V. Phone/Fax

Practice location:
  • Phone: 802-893-1200
  • Fax:
Mailing address:
  • Phone: 802-872-4343
  • Fax: 802-288-1144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD00042058
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0420012746
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: