Provider Demographics
NPI:1417023573
Name:BENTIVOGLIO, GIAN PAOLO (MD)
Entity Type:Individual
Prefix:
First Name:GIAN
Middle Name:PAOLO
Last Name:BENTIVOGLIO
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 724
Mailing Address - Street 2:NORTHEAST KINGDOM HUMAN SERVICES
Mailing Address - City:NEWPORT
Mailing Address - State:VT
Mailing Address - Zip Code:05855-0724
Mailing Address - Country:US
Mailing Address - Phone:802-334-6744
Mailing Address - Fax:802-334-7340
Practice Address - Street 1:154 DUCHESS AVE
Practice Address - Street 2:NORTHEAST KINGDOM HUMAN SERVICES
Practice Address - City:NEWPORT
Practice Address - State:VT
Practice Address - Zip Code:05855-5516
Practice Address - Country:US
Practice Address - Phone:802-334-6744
Practice Address - Fax:802-334-7340
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH87672084P0804X
VT04200105432084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTORE3322Medicaid