Provider Demographics
NPI:1417151564
Name:CARMODY, MARTIN G (DPM)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:G
Last Name:CARMODY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 ALLEN ST
Mailing Address - Street 2:STE 8
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-4564
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:69 ALLEN ST
Practice Address - Street 2:STE 8
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4564
Practice Address - Country:US
Practice Address - Phone:802-773-7151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT056-0000146213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0VN0351Medicaid