Provider Demographics
NPI:1497065098
Name:TINA D'AMATO, PC
Entity Type:Organization
Organization Name:TINA D'AMATO, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:D'AMATO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:508-498-7242
Mailing Address - Street 1:71 KNIGHT LN
Mailing Address - Street 2:SUITE 10/20
Mailing Address - City:WILLISTON
Mailing Address - State:VT
Mailing Address - Zip Code:05495-4432
Mailing Address - Country:US
Mailing Address - Phone:802-872-7001
Mailing Address - Fax:802-872-9088
Practice Address - Street 1:71 KNIGHT LN
Practice Address - Street 2:SUITE 10/20
Practice Address - City:WILLISTON
Practice Address - State:VT
Practice Address - Zip Code:05495-4432
Practice Address - Country:US
Practice Address - Phone:802-872-7001
Practice Address - Fax:802-872-9088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-15
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0320000547207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1014019Medicaid