Provider Demographics
NPI:1184633844
Name:STICKNEY, MARK C (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:C
Last Name:STICKNEY
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 1:3 COMMONS ST
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-4652
Mailing Address - Country:US
Mailing Address - Phone:802-773-7155
Mailing Address - Fax:802-773-7616
Practice Address - Street 1:3 COMMONS ST
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4652
Practice Address - Country:US
Practice Address - Phone:802-773-7155
Practice Address - Fax:802-773-7616
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2010-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0007705207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0009219Medicaid
VT0009219Medicaid
VTB85822Medicare UPIN