Provider Demographics
NPI:1447410287
Name:JOHN R. BOOKWALTER, M.D. FACS PC
Entity Type:Organization
Organization Name:JOHN R. BOOKWALTER, M.D. FACS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:BOOKWALTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:802-257-7106
Mailing Address - Street 1:15 BELMONT AVE
Mailing Address - Street 2:
Mailing Address - City:BRATTLEBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05301-6613
Mailing Address - Country:US
Mailing Address - Phone:802-257-7106
Mailing Address - Fax:802-257-2270
Practice Address - Street 1:15 BELMONT AVE
Practice Address - Street 2:
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05301-6613
Practice Address - Country:US
Practice Address - Phone:802-257-7106
Practice Address - Fax:802-257-2270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-16
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-0004468174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTB85574Medicare UPIN