Provider Demographics
NPI:1467598441
Name:MUSMAN, EVAN (DO)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:MUSMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:ONE KENNEDY DRIVE, SUITE U-1
Mailing Address - Street 2:
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-7166
Mailing Address - Country:US
Mailing Address - Phone:802-861-6100
Mailing Address - Fax:802-861-6101
Practice Address - Street 1:ONE KENNEDY DRIVE, SUITE U-1
Practice Address - Street 2:
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-7166
Practice Address - Country:US
Practice Address - Phone:802-861-6100
Practice Address - Fax:802-861-6101
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT032-0000427174400000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT39879OtherBC BS OF VT
VTP00301582OtherRR MEDICARE
VT364858OtherMVP
VN2090Medicare ID - Type Unspecified
VTP00301582OtherRR MEDICARE