Provider Demographics
NPI:1003828419
Name:PELLETIER, JOSEPH C (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:C
Last Name:PELLETIER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2000
Mailing Address - Street 2:44 SOUTH MAIN STREET
Mailing Address - City:RANDOLPH
Mailing Address - State:VT
Mailing Address - Zip Code:05060-2000
Mailing Address - Country:US
Mailing Address - Phone:802-728-2420
Mailing Address - Fax:802-728-2394
Practice Address - Street 1:44 S MAIN ST
Practice Address - Street 2:
Practice Address - City:RANDOLPH
Practice Address - State:VT
Practice Address - Zip Code:05060-1381
Practice Address - Country:US
Practice Address - Phone:802-728-2420
Practice Address - Fax:802-728-2394
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0420010598208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1009801Medicaid
VT1009801Medicaid
VTH88791Medicare UPIN