Provider Demographics
NPI:1487628608
Name:BOLDUC, THOMAS G (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:G
Last Name:BOLDUC
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 1:66 KNIGHT LN STE 10
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-9308
Mailing Address - Country:US
Mailing Address - Phone:802-872-4343
Mailing Address - Fax:802-288-1144
Practice Address - Street 1:11 HAYDENBERRY DR UNIT 103
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:VT
Practice Address - Zip Code:05468-2200
Practice Address - Country:US
Practice Address - Phone:802-893-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00042058208000000X
VT0420012746208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8364523Medicaid
VT0420012746OtherMEDICAL LICENSE
WA172210OtherL&I
OR299829Medicaid
WAP00018622OtherRAIL ROAD MEDICARE
VT1022471Medicaid
WA172210OtherL&I