Provider Demographics
NPI:1386678381
Name:NEIDER, STEPHANIE DAWN (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:DAWN
Last Name:NEIDER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:370 SHELBURNE RD.
Mailing Address - Street 2:#4452
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:NORTHERN VERMONT DERMATOLOGY
Practice Address - Street 2:53 FAIRFAX ROAD SUITE 2
Practice Address - City:ST. ALBANS
Practice Address - State:VT
Practice Address - Zip Code:05478
Practice Address - Country:US
Practice Address - Phone:833-688-3376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301086785207N00000X
VT042.0013164207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4819846Medicaid
OHH098680Medicare PIN
MI4819846Medicaid